Elbow is the most common joint to dislocate in children. Posterior dislocation is most common. Simple dislocations are those without fracture. Complex dislocations are those that occur with an associated fracture

1. ELBOW DISLOCATIONS

2. Introduction
• MC jt to dislocate in children.
• Age 10-20yr (shallow trochlear notch of ulna)
• 2nd MC jt to dislocate in adults.
• Posterior dislocation is most common.
• Simple dislocations are those without fracture.
• Complex dislocations are those that occur with an associated fracture

3. Stability
Anterior-posterior:
Trochlea-olecranon fossa (extension) coronoid fossa
Radiocapitellar joint,
Biceps-triceps-brachialis (dynamic).
Valgus:
The medial collateral ligament (mcl) complex: the anterior bundle is the primary
stabilizer in flexion and extension
The anterior capsule
 radiocapitellar joint function in extension.
Varus:
The lateral collateral ligament is static
Anconeus muscle is dynamic.

6. Mechanism Of Injury
• Posterior dislocation
This is a combination of elbow hyperextension, valgus stress, arm
abduction, and forearm supination.
• Anterior dislocation
A direct force strikes the posterior forearm with the elbow in a flexed
position.
Fracture dislocation is always better than simple dislocation

7. • Hori’s circle
Lateral to medial
direction

8. Classification
• Simple versus complex (associated with fracture)
• According to the direction of displacement of the ulna relative to the
humerus :
• Posterior - MC
• Posterolateral
• Posteromedial
• Lateral
• Medial
• Anterior
• Divergent

9. Treatment principles
• Restoration of the inherent bony stability of the elbow is the goal.
• The trochlear notch (coronoid and olecranon), radial head, and lateral
collateral ligament should be repaired or reconstructed, but the MCL rarely
needs to be repaired.
• If the elbow is stable, or can be made stable with surgery on the lateral
side, the MCL will heal properly with active motion, and its repair will not
be necessary for stability.
• Morrey recommended that the elbow should not redislocate before
reaching 45 degrees of flexion from a fully flexed position--- Jupiter and
Ring recommended that the elbow should be able to go to 30 degrees
before substantial subluxation or dislocation.

10. Types of Elbow Instability
1.Posterolateral Rotatory Instability
This occurs during a fall on to the outstretched arm that create a
valgus, axial, and posterolateral rotatory force. The ulna and the
forearm supinate away from the humerus and dislocate posteriorly.
This may result in injury to the radial head or coronoid.
The soft tissue injury proceeds from lateral to medial, with the
anterior band of the MCL being the last structure injured.
It is possible to dislocate the elbow with the anterior band of the MCL
remaining intact

12. 2. Varus, Posteromedial Rotational Instability
This occurs with a fall onto the outstretched arm that creates a varus
stress, axial load, and posteromedial rotational force to the elbow. This
results in fracture of the anteromedial facet of the coronoid process
and
(1) injury to the lateral collateral ligament,
(2) fracture of the olecranon, or
(3) an additional fracture of the coronoid at its base.
3. Anterior Olecranon Fracture-Dislocations
These result from a direct blow to the flexed elbow.

13. A. Parvin’s B. Meyn and Quingley

14. Operative
• Unstable – repair LCL
• Fracture-Dislocation

15. Neglected elbow dislocation
• Before 3 weeks – CR is possible.
• The neglected dislocation of more than 3 weeks which is categorized
as old unreduced dislocation usually requires surgical treatment.

16. Pathological anatomy
• Myositic ossificans around the Joints, especially in brachialis and triceps
• Marked shortening of triceps and medial/ lateral collateral ligaments.
• The ulnar nerve may get tightened with attempts at flexion.
• Dense fibrous thickening of the joint capsule with extensive dense fibrous
tissue filling the olecranon and coronoid fossa -- ROM
• Disuse – osteopenia of bones and malnutrition of the articular cartilage.
• Ulnar nerve is often remarkably scarred and, found tight in the ulnar
groove.

17. Radio-humeral horn- HO

18. Clinical presentation
• H/O trauma, took treatment from osteopath.
• Reduced ROM
• Inability to flex
• Attitude: Elbow extended with or without some degrees of flexion
• Inspection: Bamboo splint marks and Abnormal prominence of
olecranon

19. • Palpation
Abnormal prominence of distal humerus in the cubital fossa
Posterior and proximal migration of olecranon
• Movements
10-30 of flexion
Pronation is more reduced than supination
• Measurements
Forearm length is reduced.

20. X-rays
• Type of dislocation
• To see for fracture
• Myositic mass
• Osteopenia

21. Treatment
• Closed reduction
• Open reduction
• Excision arthroplasty
• Interposition or replacement arthroplasty
• Arthrodesis.

22. Closed reduction
• Not possible because:
• Soft tissue contracture
• Iatrogenic fracture (osteopenia)
• Ulnar nerve injury

23. Open Reduction – No time limit (in childrens
only)
Speed’s posterior midline approach
• Fibrous tissue from olecranon, coronoid fossa, radio-capitular jt.
• Lengthen triceps – V-Y plasty (if more than 2 months). Sx causes some
shortening
• Repair of MCL and LCL
• Anterior transposition of ulnar nerve ± (assess tension after flexion upto
90)
• K-wire or Steinmann pin – ulno-humeral or radio-capitular – 2-3 weeks
Hinged ex fix for 8 weeks (not in speed’s)
In adults upto 3 months – good results

24. Rehab
• Immobilization for 2 weeks
• Intermittent mobilization of 70-120 of flexion for 2 weeks
• Aggressive mobilization

25. ELBOW ARTHROPLASTY – depends on the
articular cartilage
• Adult elbow that has remained unreduced for longer than 3 to 6
months may require some type of elbow arthroplasty or perhaps
arthrodesis
• In cases of chronic dislocation with significant joint degeneration or
incongruity in a patient too young for total elbow replacement (who
declines arthrodesis), interpositional arthroplasty using fascia lata or a
similar graft may be the best choice.