Case Study 2.1: Acute Elbow Dislocation
SETTING: EMERGENCY DEPARTMENT FOLLOWED UP AT SPORTS MEDICINE CLINIC
Definition and Incidence
The elbow is the second most commonly dislocated major joint in the general population and the fifth most commonly injured body part in young athletes (Adirim & Cheng, 2003; Dizdarevic et al., 2015). The National Electronic Injury Surveillance System database demonstrates the highest incidence of elbow dislocations occurring between the ages of 10 and 19, with sports participation being the most frequent cause of injury (Stoneback et al., 2012). The elbow is a hinge joint that relies heavily on the congruency of the distal humerus and proximal ulna for stability. There are three joint articulations that make up the elbow: humeroulnar, humeroradial, and radioulnar. These three joints allow for elbow flexion, extension, pronation, and supination. An elbow dislocation typically occurs from falling on an outstretched hand (FOOSH), with the forearm supinated, wrist extended, and the elbow flexed 20 degrees or less. This mechanism causes an axial load toward the elbow joint, increasing stress across the surrounding ligamentous structures, and ultimately leads to a potential dislocation event. Dislocations are classified in the direction of movement: anterior, posterior, medial, or lateral, with posterolateral being the most common direction for elbow dislocations. Elbow dislocations are also described as either simple (no fracture) or complex (evidence of fracture).
Patient is an 11-year-old, left-hand-dominant male.
Patient is an 11-year-old, left-hand-dominant male, who has no pertinent past medical or surgical history and no previous injuries to his elbow. He is active and participates in football.
He presents to the emergency department (ED) with a chief complaint of right elbow pain. The patient described an event while playing running back in a football game. He was running with the ball in his left hand, was tackled and fell to the ground onto an outstretched right upper extremity. He experienced immediate pain with obvious deformity noted at the right elbow. Upon arrival to the ED, the patient reported moderate pain with guarding of his right elbow at approximately 90 degrees of flexion. On physical exam, obvious deformity of the humeroulnar joint was seen and felt, the presence of a distal radial pulse was felt, skin appeared pink and warm, and the patient had normal sensory distribution of the radial, median, and ulnar nerves, with intact motor function along the distribution of his anterior interosseous, posterior interosseous, and ulnar nerves. He demonstrated minimal range of motion (ROM) at the right wrist and fingers limited by pain, discomfort, and an unwillingness to move. As this was his nondominant arm, the impact of his scholastic activities may not be as high as compared to an injury of his dominant arm.
Radiographs were obtained, anterior–posterior (AP) and lateral views (Figure 2.1). The lateral view confirmed a posterolateral dislocation of his right elbow. The distal humerus was anterior to the coronoid process of the ulna. The radius and ulna appeared to have maintained a normal relationship with each other. No fractures were evident on x-rays. Postreduction AP and lateral radiographs were taken (Figure 2.2). Because no fractures were evident on radiographs and stability was maintained through passive ROM postreduction, further advanced imaging was not warranted.
The patient underwent a conscious sedation in the ED to perform the reduction. Joint reduction is required in an urgent manner to decrease the risk of further damage to the surrounding neurovascular structures. After reduction was completed, secondary radiographs were performed to confirm congruent reduction and ensure that no fractures or incarcerated fragments were seen within the joint. The patient was then placed in a posterior fiberglass splint in approximately 90 degrees of elbow flexion with the forearm in neutral as the elbow was stable through a full passive ROM following reduction. He was instructed to follow up in 1 week following reduction at the sports medicine/orthopedic clinic.
Educate the patient and the family about the importance of physical therapy and working on gradually increasing ROM and restoring strength. Instruct the patient to remain in the brace at all times except during physical therapy appointments.
Continuation of treatment included subsequent follow-up appointment at an outpatient sports medicine clinic. At 8 days following the injury, the patient reported improvement in pain and swelling. Radiographs were obtained to confirm a maintained elbow joint reduction and no evidence of fractures. At this time the splint was removed in order to assess that the distal neurovascular exam remained intact. He was able to tolerate passive ROM from 60 to 100 degrees without pain, and was placed in a hinged elbow brace locked at 90 degrees for 1 more week. At 2 weeks status after right elbow dislocation, the hinged elbow brace was opened from 75 to 100 degrees. The hinged brace was removed at week 6. At weeks 2, 6, and 11 postreduction, his ROM was 30 to 110 degrees, 10 to 130 degrees, and 0 to 130 degrees, respectively. At 11 weeks following the injury he demonstrated full, stable, pain-free ROM, and full strength. As a result, he was cleared to return to full, unrestricted sports participation.
Simple dislocations, as seen in this case, have a good prognosis and low rate of future instability (Middleton & Anakwe, 2012). It has been shown in the literature for simple elbow dislocations that early active ROM while maintaining joint stability in the rehabilitation program is crucial in predicting better long-term outcomes (Armstrong, 2015).
Adirim, T. A., & Cheng, T. L. (2003). Overview of injuries in the young athlete. Sports Medicine, 33(1), 75.
Armstrong, A. (2015). Simple elbow dislocation. Hand Clinics, 31, 521–531.
Dizdarevic, I., Low, S., Currie, D. W., Comstock, R. D., Hammoud, S., & Atanda, A. (2016). Epidemiology of elbow dislocations in high school athletes. American Journal of Sports Medicine, 44(1), 202–208.
Middleton, S. D., & Anakwe, R. E. (2012). Focus on elbow dislocation. Journal of Bone & Joint Surgery.
Stoneback, J. W., Owens, B. D., Sykes, J., Athwal, G. S., Pointer, L., & Wolf, J. (2012). Incidence of elbow dislocations in the United States population. Journal of Bone & Joint Surgery, American, 94-A(3), 240–245.
Case Study 2.2: Acute Nursemaid’s Elbow (annular ligament displacement)
Kimberly A. Joerg
SETTING: ORTHOPEDIC URGENT CARE
Definition and Incidence
Nursemaid’s elbow or annular ligament displacement was formerly termed “radial head subluxation.” Most commonly, the injury is seen in children between ages 1 and 4, and occurs when there is a sudden forceful traction on the hand when the forearm is pronated and the elbow is extended (Browner, 2013).
A 3-year-old girl presents with her mother. The mother states, “My daughter has not been using her left arm since this afternoon.” According to the mother, earlier this afternoon the father was helping child put on her coat and pulled child’s arm through sleeve. Since then, parents have noticed that she has not been using left arm and continues to hold it very still. Otherwise the child is healthy, no prior hospitalizations or surgeries, is up to date with immunizations, and has no known allergies. She is not using the left arm, but is using all other extremities per parents; no rashes; denies numbness or tingling.
The child is sitting on mother’s lap guarding left arm and holding it still against her body. She is not actively moving or using it, even when prompted with a sticker. There is no swelling, redness, or bruising noted of left arm. On palpation, there is mild tenderness at left radial head. The bilateral upper extremities are warm, pink, brisk capillary refill, positive radial pulse, positive sensation, positive motion noted of right upper extremity. However, there is minimal movement of left arm and fingers of left hand.
Standard of care recommends that radiographs of elbow are not necessary unless after two attempts to reduce, the elbow does not return to baseline or there is suspicion of a fracture (Browner, 2013). Ultrasound and MRI may also be utilized if history is not clear, two attempts at reduction are not effective, or if injury or tear to ligament is suspected (Wolfman, 2015).
Nursemaid’s elbow, annular ligament displacement.
The child was kept in the parent’s lap, the child’s left elbow was held in the provider’s hand. With the provider’s other hand, the left forearm was pronated then fully extended, no “click” was felt by the provider after the attempt. After observing the child for 30 minutes, there was limited movement of the left arm. The procedure was repeated using more traction and a “click” was felt (Browner, 2013). After the second attempt of the pronation technique, the child was observed using and moving the left arm without difficulty within 30 minutes. She reached for a popsicle and was able to bring it to her mouth with her left arm. Her parents were educated about incidence of reoccurrence (up to one third) and to avoid tugging motion to the arms (Browner, 2013). The child was discharged without any restrictions.
It is important to educate the family on the mechanism of injury for annular ligament displacements (nursemaid’s elbow), and how to prevent future incidents.
Generally, no follow-up is necessary for this injury. It is good practice to educate the family and to avoid future incidents. Provide information to the family to seek follow-up if the child is demonstrating any unexpected changes in use of the arm, pain, numbness, or any concerning symptoms.
Browner, E. (2013). Brief: Nursemaid’s elbow (annular ligament displacement). Pediatrics in Review, 34(8), 366–367.
Wolfram, W. (2015). Nursemaid elbow. Retrieved from http://emedicine.medscape.com/article/803026-overview