Elbow Dislocation - dnbid lecture 2012

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Elbow Dislocation & Physiotherapy:

Elbow Dislocation & Physiotherapy Dr. D. N. Bid [PT]

PowerPoint Presentation:

The elbow joint displays an elegant balance between stability and mobility. While allowing a wide range of motion, the joint has an inherent stability that requires a considerable force to dislocate. As a result, a significant percentage—approximately one third of elbow dislocations—are associated with fractures of bony components of the elbow.

PowerPoint Presentation:

Dislocations without associated fracture are termed simple, while dislocations with accompanying fracture are termed complex .

Pathoanatomy :

Pathoanatomy Elbow dislocation is associated with complete or near complete disruption of capsuloligamentous stabilizers Progression of injury is from lateral to medial LCL fails first  by avulsion of lateral epicondylar origin midsubstance LCL tears are less common but do occur MCL fails last depending on degree of energy

Pathomechanics – Stages:

Pathomechanics – Stages Three Stages of Elbow Dislocation Stage 1 LUCL Disruption Posterolateral Rotary Instability (PLRI) Resultant elbow subluxation

Pathomechanics – Stages:

Pathomechanics – Stages Three Stages of Elbow Dislocation Stage 2 Additional disruption anteriorly and posteriorly Resultant perched dislocation

Pathomechanics – Stages:

Pathomechanics – Stages Three Stages of Elbow Dislocation Stage 3 – Full Dislocation (subdivided) Stage 3A Disruption of all joints surrounding tissues and MCL Posterior Bundle. MCL Anterior Bundle still intact Dislocation via PLR mechanism still permitted

Pathomechanics – Stages:

Pathomechanics – Stages Three Stages of Elbow Dislocation Stage 3 – Full Dislocation (subdivided) Stage 3B Entire MCL Disrupted Valgus, Varus, and Rotary Instability are all present post reduction

Pathomechanics – Stages:

Pathomechanics – Stages Three Stages of Elbow Dislocation Stage 3 subdivided Stage 3C Entire aspect of humerus stripped of soft tissues Instability so severe dislocation can occur when immobilized at 90 ° of FLX Reduction only maintained at 110° of FLX

Pathomechanics – Horii Circle:

Pathomechanics – Horii Circle Process through Stages of Dislocation Associated w/ Torn Capsule Fractures vs MCL

Pathomechanics – PLRI Test:

Pathomechanics – PLRI Test Elbow Lateral Pivot Shift Test Position Action Positive Finding

Pathomechanics – PEFR :

Pathomechanics – PEFR Pathological External Forearm Rotation Another hypothesis Definition External Rotation of the forearm complex relative to the humerus translating the radial head off of the humeral capitellum. Possible Precursor to PLRI and subsequently Elbow Dislocation

PowerPoint Presentation:

Most commonly, the elbow dislocates posteriorly. Immediate reduction is essential to reduce the risk of neurovascular or cartilaginous complications. Hence, this will be discussed here in detail.

Definition of Posterior Elbow Dislocation :

Definition of Posterior Elbow Dislocation Posterior elbow dislocation (PED) occurs when the radius and ulna are forcefully driven posterior to the humerus. Specifically, the olecranon process of the ulna moves into the olecranon fossa of the humerus and the trochlea of the humerus is displaced over the coronoid process of the ulna. PED is classified as simple or complex and staged according to severity.

Image 1: Elbow dislocation :

Image 1: Elbow dislocation

Epidemiology /Etiology :

Epidemiology /Etiology In children under 10 years, PEDs are the most common type of joint dislocation. In adults, they are the second most commonly dislocated joint proceeded by shoulder dislocations. Elbow dislocations annually affect between 6 and 7 people per 100,000. Approximately 90% of all elbow dislocations are directionally classified as posterior or posterolateral and are more commonly seen in the non-dominant upper extremity (UE).

PowerPoint Presentation:

Typically, this injury is caused by a traumatic fall onto an outstretched arm resulting in an hyper-extension injury. However, more recent research has suggested that axial compression, elbow flexion, valgus stress, and forearm supination lead to a rotational displacement of the ulna on the distal humerus. Most commonly, the dislocation is associated with a damaged or torn anterior capsule.

PowerPoint Presentation:

PED can be classified as simple (74%) or complex (26%). A simple dislocation is absent of fractures while a complex dislocation has related fractures. Fractures may exist on the radial head, coronoid process, olecranon , humeral condyles, or capitellum . These fractures may lead to disruption of the medial collateral ligament (MCL), lateral collateral ligament (LCL), or interosseous membrane.

PowerPoint Presentation:

'Terrible triad' is a term used to describe a severe complex dislocation with intra-articular fractures of the radial head and coronoid process. Elbow dislocations are staged depending on the disruption of the following stabilizers: the ulnohumeral articulation, MCL, and LCL.

PowerPoint Presentation:

Table 1 Adapted from O’Driscoll SW, Jupiter JB, King GJW, Hotchkiss RN, Morrey BF. The unstable elbow. J Bone Joint Surg. 2000;82-A(5):724-738.

Characteristics/ Clinical Presentation :

Characteristics/ Clinical Presentation After a PED, a person may feel immediate instability. Depending on the severity of the damage, they may report a 'popping' sensation or noise upon dislocation. With palpation and observation, the olecranon is prominent creating a divot over the distal triceps. After reduction, radial-sided elbow pain may persist in addition to 'snapping' with supination. Swelling, joint line tenderness, and decreased range of motion (ROM) should be expected.

PowerPoint Presentation:

Various degrees of injury are also seen in muscles surrounding the elbow that originate at the medial or lateral epicondyles. When ligaments are not compromised, recurrent dislocations are not common.

Differential Diagnosis :

Differential Diagnosis To diagnose PED, radiographs in the anterior, posterior, and lateral views with valgus stress are obtained. Table 2: below depicts other injuries that should be considered when suspecting PED.

Examination :

Examination Physical therapy examination should include a vascular and neuromuscular screen, observation, palpation, muscle testing, ROM, and special ligamentous tests. The following information outlines ways to test for potential impairments after PED. A vascular assessment should include palpation of the brachial, radial, and ulnar arteries. During the neuromuscular screen, dermatomes, myotomes , and reflexes should be evaluated with emphasis on the ulnar , median, and radial nerves. Observe the elbow for any ecchymosis , rubor , or deformities. During palpation, a disrupted triangle sign may indicate joint dislocation.

PowerPoint Presentation:

The triangle sign is obtained by palpating the tip of the olecranon , medial, and lateral epicondyles while in elbow flexion, resulting in a triangle configuration.

PowerPoint Presentation:

It is essential to palpate for associated fractures in the elbow complex. The elbow extension sign can be used to rule out a fracture. Specific muscles that attach to the elbow should be evaluated including the elbow and wrist flexors/extensors and supinators / pronators .

PowerPoint Presentation:

Documentation of elbow ROM is necessary when following the progression of rehabilitation. Other outcome measures include the Mayo Elbow Performance Index (MEPI) and the Disabilities of the Arm, Shoulder, and Hand (DASH). Patients with PED may also have concomitant collateral ligament ruptures at the elbow. If this occurs, the patient will be at greater risk of developing recurrent instability. To assess for this, the following special tests should be performed: varus and valgus stress test, the lateral pivot-shift test (Posterolateral Rotational Instability Test) (see Image 3), and apprehension testing.

PowerPoint Presentation:

Physical therapists should be alert for the following potential complications associated with PED: neurological deficits including hypoaesthesia of the hand in the ulnar nerve distribution, concomitant fractures, myositis ossificans , and degenerative changes in the joint. Radiographs are indicated when there is no response to care after four weeks of conservative treatment, significant activity restriction for more than four weeks, or non-mechanical pain is present.

As with all patients, clinicians should be aware of red flags listed in Table 3 below. :

As with all patients, clinicians should be aware of red flags listed in Table 3 below. Table 3 Adapted from Bussieres AE, Peterson C, Taylor JA. Diagnostic imaging guideline for musculoskeletal complaints in adults - an evidence-based approach. Part 2: upper extremity disorders. J Manipulative Physiol Ther 2008 Jan;31(1):2-32.

Medical Management :

Medical Management Before surgery is considered, research indicates reduction under local or general anesthesia as the primary treatment for PED. Patient presentation including elbow stiffness and pain are key factors when considering the need for surgery along with irreducible dislocation, gross instability, neurovascular injuries, and associated fractures. The most common surgical options include an open procedure, with or without Speed's procedure, and excision or closed arthroplasty.

PowerPoint Presentation:

An open procedure, more commonly seen in neglected PED < three months, involves ulnar nerve release, humeroulnar and humeroradial reduction, possible triceps lengthening using Speed's procedure, and wires and/or screws placed in the olecranon for stabilizing the joint. In the Elzohairy study, within two weeks the wires were removed and active motion was initiated, while the screws were removed six months after surgery. Excision arthroplasty is also used when patients present with neglected PED, but studies suggest high reoccurrences of pain and instability.

PowerPoint Presentation:

Ligaments injured with fractures or dislocations are repaired via sutures attaching them back to the bone. Once surgery is complete, the patient is immobilized with time frames varying based on the individual and the surgeon's protocol. Hinged braces, fixators , plaster casts, and slings are utilized to keep the elbow in a position of approximately 70-80 o of flexion and slight pronation.

PowerPoint Presentation:

Active movement is usually initiated between three to fourteen days, with slow, gradual supination. When treating a post-surgical PED patient, physical therapists should be cautious of pin site infection. A patient is able to return to functional activities around twelve weeks and sports around six months.

Physical Therapy Management :

Physical Therapy Management While nonsurgical treatment approaches to PED can vary depending on the level of tissue involvement. PED can occur on a continuum of severity; therefore, the treatment must be diverse as well. Treatment can vary from aggressive immediate AROM to traditional plaster immobilization for several days. If a fracture occurs secondary to dislocation, intra-articular bone fragments and fracture position may dictate treatment. Closed or nonsurgical reduction by a physical therapist is only performed if there are no associated fractures.

PowerPoint Presentation:

Uhl et al. described one technique for reduction: the patient hangs their affected arm over the back of a chair as the clinician tractions the ulna in a downward direction. After reduction of the joint, instability is evaluated. A splint should be applied and the patient should be referred for radiographs if the joint subluxes or dislocates while assessing instability. If left untreated (unreduced) patients may develop soft tissue contractures and localized osteoporosis.

PowerPoint Presentation:

The following clinical decision-making algorithm for immobilization and surgical options can be used following acute dislocations.

PowerPoint Presentation:

Decision-Making Algorithm: Adapted from O’Driscoll SW, Jupiter JB, King GJW, Hotchkiss RN, Morrey BF. The unstable elbow. J Bone Joint Surg. 2000;82-A(5):724-738.

PowerPoint Presentation:

Surgical Treatment Algorithm: Adapted from O’Driscoll SW, Jupiter JB, King GJW, Hotchkiss RN, Morrey BF. The unstable elbow. J Bone Joint Surg. 2000;82-A(5):724-738.

PowerPoint Presentation:

Generally following reduction the patient is placed in a posterior splint at 45-90 o of elbow flexion for three days to three weeks. Evidence reveals detrimental effects of prolonged immobilization including flexion contractures , enhanced perception of pain , and increased duration of disability , all of which prolong the rehabilitation process. Throughout the immobilization phase, wrist and shoulder function should be maintained through ROM and strengthening exercises.

PowerPoint Presentation:

Inflammation is a common sequela following PED and can be addressed using compression, ice, and effleurage. When the patient no longer requires immobilization, functional treatment begins with gentle AROM and PROM exercises in a pain-free range targeting the entire UE.

PowerPoint Presentation:

Multi-angle isometric activities and PNF patterns for the elbow help decrease pain, increase ROM, and begin to target strengthening components in the preliminary stages of recovery. When pain is no longer a barrier to treatment, functional progressive resistance exercises should be implemented to improve total UE muscle strength and endurance.

PowerPoint Presentation:

Although full extension should be a goal of rehabilitation, care must be taken to protect the vulnerable elbow and avoid hyperextension. It is important to be cautious during passive mobilization and ROM. Multiple articles have warned that aggressive PROM (especially into extension) and forceful manipulation may cause myositis ossificans and should be avoided.

PowerPoint Presentation:

Also, Uhl et al. suggested that any valgus stress applied to the elbow should be avoided throughout treatment so not to stress the already compromised tissues. Therapeutic goals in the later phase of rehabilitation include attaining full ROM and strength capabilities of the entire affected arm, suppression of pain, and restoration of functional abilities to pre-injury level.

Clinical Bottom Line :

Clinical Bottom Line It is important to explore the level of severity and degree of complication associated with each PED since this dictates the patients' prognoses. Patients who have had simple PED with early reduction usually have good outcomes.

PowerPoint Presentation:

In most cases, there is potential for developing instability and degenerative joint disease. Overall the best treatment for PED is initial short term restricted motion (usually two weeks or less) followed by early mobilization including PROM and progressing to AROM and functional strengthening. Long duration plaster of Paris immobilization has been show to have poorer functional outcomes.

Hinged Brace. :

Hinged Brace.

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Nursemaid’s Elbow:

Nursemaid’s Elbow Relatively common disorder in children between 1 to 4 years of age. Sudden traction on the extended pronated forearm is the usual mechanism. X-ray examination tends to be normal. The child resists any movement of the elbow. Parents usually present the child with complaint of wrist pain.

Nursemaid’s Elbow:

Nursemaid’s Elbow

Nursemaid’s Elbow:

Nursemaid’s Elbow Pathology The mechanism of this injury is a tear of the distal attachment of the orbicular ligament. The radial head is able to slip partially through this ligament with the forearm pronated. The orbicular ligament then becomes interposed between the articular surface of the radial head and the capitellum.

Nursemaid’s Elbow:

Nursemaid’s Elbow Interposition of torn Annular ligament

Nursemaid’s Elbow:

Nursemaid’s Elbow Presentation The patient is a young child (less than 4 years old) The elbow is tender laterally, but it can be moved in flexion and extension. The child holds the arm pronated and slightly flexed and refuses to supinate it.

Nursemaid’s Elbow:

Nursemaid’s Elbow Manipulative Reduction Grasp the wrist with one hand with the forearm extended and With the other, grasp the elbow with the thumb resting over the radial head.

Nursemaid’s Elbow:

Nursemaid’s Elbow Manipulative Reduction As the forearm is fully supinated Apply firm pressure on the radial head and Push the forearm directly upward.

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Treatment and Rehabilitation of Elbow Dislocations Kevin Wilk, PT, James R. Andrews, MD:

Treatment and Rehabilitation of Elbow Dislocations Kevin Wilk , PT, James R. Andrews, MD Re habilitation Considerations • Elbow dislocations constitute 10 to 25% of all injuries to the elbow. • Ninety percent of elbow dislocations produce posterior or posterolateral displacement of the forearm relative to the distal humerus . • Fractures associated with elbow dislocations most frequently involve the radial head and the coronoid process of the elbow. • The distal radioulnar joint (wrist) and the interosseous membrane of the forearm should be examined for tenderness and stability to rule out a possible Essex- Lopresti injury.

PowerPoint Presentation:

When intra- articular fractures of the radial head, olecranon , or coronoid process occur with elbow dislocation, this is termed a complex dislocation. • Associated neurologic injury is very uncommon, with the ulnar nerve the most commonly injured (stretch neurapraxia ). A minor (but permanent) loss of terminal elbow extension (5 -15 degrees) is the most common sequela after posterior elbow dislocation. • Pronation and supination are characteristically unaffected after this injury. ??????????? • Elbow flexion returns first, with maximal improvement usually taking 6 to 12 weeks. Elbow extension returns more slowly and may continue to improve for 3 to 5 months.

PowerPoint Presentation:

Prolonged rigid immobilization has been associated with the least satisfactory arc of elbow motion and should be avoided. • Heterotopic ossification (calcification) is common after elbow dislocation (up to 75% of patients) but rarely limits motion (fewer than 5% of patients). The most common sites for periarticular calcification are the anterior elbow region and the collateral ligaments. • Mechanical testing confirms a 15% average loss of elbow strength after elbow dislocation. • Approximately 60% of patients do not believe the injured elbow is as "good" as the uninvolved elbow at the end of treatment.

Classification :

Classification The traditional classification of elbow dislocations divides injuries into anterior (2%) and posterior dislocations. Posterior dislocations are further subdivided according to the final resting position of the olecranon in relation to the distal humerus : posterior, posterolateral (most common), posteromedial (least common), and pure lateral. Money makes a clinical distinction between complete dislocation and perched dislocation (Fig. 2-22). Because perched dislocations have less ligament tearing, they have a more rapid recovery and more rapid rehabilitation. For a complete elbow dislocation, the anterior capsule must be disrupted. The brachialis must also be torn or significantly stretched.

PowerPoint Presentation:

Many elbow dislocations are accompanied by some type of UCL involvement. More specifically, the anterior oblique band of the UCL is affected. Tullos and colleagues found that the anterior oblique band of the UCL was torn in 34 of 37 patients who had previously experienced a posterior elbow dislocation. Repair of this ligament is sometimes indicated in athletes if the injury occurs in the dominant arm. This optimizes the chance for full return to the athlete's previous level of competition.

Evaluation, Work-up, and Reduction :

Evaluation, Work-up, and Reduction • Swelling and deformity are noted on initial inspection. • Concomitant upper extremity injuries should be ruled out by palpation of the shoulder and wrist. Complete neurovascular examinations should be done before and after reduction.

PowerPoint Presentation:

For posterior dislocations: The player is removed from the field with the arm supported. A neurovascular examination is done, and the patient is placed prone with the arm flexed at 90 degrees over the edge of the table (Fig. 2-23). Any medial or lateral translation of the proximal ulna is gently corrected. The physician grasps the wrist and applies traction and slight supination of the forearm to distract and unlock the coronoid process from the olecranon fossa . An assistant places countertraction on the arm. Pressure is applied to the olecranon while the arm is pronated (i.e., palm down) to complete the reduction. An obvious "clunk" indicates reduction.

PowerPoint Presentation:

Neurovascular examination is repeated and elbow instability is evaluated by placing the elbow through a gentle ROM, watching for instability as the elbow is extended. Instability noted at a certain degree of extension (e.g., 20 degrees) should be documented and conveyed to the therapist. The arm is placed in a sling (at 90 degrees) and iced and elevated. If an immediate on-the-field reduction cannot be performed, muscle relaxation in the emergency room is of great importance. Radiographs ( anteroposterior [AP] and lateral) of the elbow, forearm, and wrist are obtained to ensure that no associated fractures are present.

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