You are called to assess 14-year old Oliver who has presented to your ED by ambulance with an elbow injury. He dived to make a save while playing football and landed on his outstretched hand. He reports feeling a click in his elbow, followed by excruciating pain. He was given methyoxyflurane in the ambulance which has helped.
Assessment of any child and examination of their elbow should be approached in an age-appropriate and systematic way. In addition to examining for bony tenderness, vascular and neurological status should be tested.
Oliver’s elbow looks significantly swollen, deformed and bruised. You feel for a radial pulse – it’s there – and undertake a neurovascular assessment, which is intact. You prescribe him some intranasal fentanyl and order AP and lateral x-Rays of his elbow.
The elbow is an incredibly stable joint due to the way the humerus and ulna articulate (giving anterior-posterior and varus-valgus stability), strengthened by the medial and lateral collateral ligaments and the joint capsule. Muscles and tendons further strengthen this ring. A significant amount of force is needed to dislocate the elbow.
Traumatic dislocation of the elbow is rare in the paediatric population comprising only 3-6% of all childhood elbow injuries, but the most common large joint dislocation (Lieber et al., 2012). It is usually the result of a fall onto an outstretched hand, often with a large amount of force involved.
Clinically, it is obvious that there is significant injury around the elbow; this is not something you will miss or be tempted not to x-ray. Displaced supracondylar fractures can sometimes be confused with elbow dislocation as both present with a grossly swollen elbow and significant pain. A quick and easy way to distinguish the two clinically is to palpate for the equilateral triangle formed by the olecranon and the two epicondyles: this is lost in elbow dislocation as the humerus creates a fullness in the antecubital fossa. There is no need to check movements in a deformed elbow but be sure to undertake a neurovascular assessment as a priority.
The easiest way to classify simple elbow dislocations is by describing the direction of ulna dislocation in relation to the distal humerus.
90% of paediatric elbow dislocations are postero-lateral with the radiographic appearance as below:
But beware: elbow dislocations rarely present in isolation. They often coexist with other elbow injuries. Associated fractures are likely to occur prior to closure of the epiphyses; when they are closed, collateral ligaments are likely to be ruptured (Lieber et al., 2012). The most common associated fracture is a medial epicondyle avulsion which can become incarcerated in the joint – scrutinize the elbow x-rays for associated fractures. This illustrates the importance of knowing CRITOE.
Oliver returns from x-ray and you review his films. You note the posterior dislocation but cannot see any associated fractures on Oliver’s films. You contact your orthopaedic team for further assistance.
Management
Many elbow dislocations reductions can be carried out in the emergency department with adequate muscular relaxation and appropriate analgesia. A reasonable amount of force is often required to achieve reduction using traction on the forearm with counter-traction around the elbow. This should be carried out or supervised by a clinician experienced in the procedure.
Common pitfalls in elbow reduction
Be very careful to conduct a thorough neurovascular assessment before attempting reduction. The brachial artery and median nerve may become stretched over the displaced proximal ulna and ulnar nerve can become damaged when medial epicondyle avulsions complicate elbow dislocations. If a deficit is found after reduction you need to know whether it was present before you attempted relocation…
And if you can’t reduce the dislocation go back and have another look at the x-ray – it could be due to an avulsed medial epicondyle in the joint. Any elbow dislocation with an incarcerated piece of avulsed bone in the joint must be reduced in theatre and not in the ED.
Complications
Possible complications following elbow dislocation include residual limitation of the range of movement, recurrent instability, neurovascular injury, avascular necrosis of the epiphyses and degenerative arthritis. Early diagnosis and stable reduction, with fixation of concomitant fractures if necessary, are generally associated with better outcomes. For the Emergency department clinician, it is therefore critical that children with this injury are assessed and managed with the minimum possible delay, ensuring that associated fractures are recognised and managed appropriately.
After sedation with ketamine, Oliver’s elbow is reduced in the department with a satisfying clunk signifying reduction. His elbow is put through a full range of movement to test joint stability and an above elbow backslab applied. You order repeat x-Rays to evaluate the position and to check for the joint spacing and any fracture fragments within the joint as this would require surgical intervention. The post-reduction films are good and Oliver’s neurovascular assessment remains normal and he leaves your ED with a follow-up appointment in fracture clinic in a week’s time.
References
Cadogan, M. (2019) Elbow Dislocation https://lifeinthefastlane.com/elbow-dislocation/
Edgington, J. (2018) Elbow Dislocation – Pediatric.
https://www.orthobullets.com/pediatrics/4013/elbow-dislocation–pediatric
Lieber, J., Zundel, S., Luithle, T., Fuchs, J., & Kirschner, H-J. (2012) Acute traumatic posterior elbow dislocation in children. Journal of Pediatric Orthopaedics B. 21(5) 474-481
Rasool, M. N. (2004). Dislocations of the elbow in children. The Journal of Bone and Joint Surgery, 86, 1050–1058.
Sibenlist, S. & Biberthaler, P. (2019) Simple Elbow Dislocations in Biberthaler, P., Sibenlist, S. & Waddell, J.P. Acute Elbow Trauma. Fractures and dislocation injuries (eBook). Springer
Sofu, H., Gursu, S., Camurcu, Y., Yildirim, T., & Sahin, V. (2016). Pure elbow dislocation in the paediatric age group. International Orthopaedics, 40(3), 541–545
