Dislocated Elbow

Description
When the joint surfaces of an elbow are separated, the elbow is dislocated. Elbow dislocations can be complete or partial. In a complete dislocation, the joint surfaces are completely separated (Figure 1a). In a partial dislocation, the joint surfaces are only partly separated. A partial dislocation is also called a subluxation (Figure 2).

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The elbow is stable due to bone surfaces, ligaments (which connect bones) and muscles. When an elbow dislocates, all of these can be injured to different degrees. A simple dislocation does not have any major bone injury. A complex dislocation can have severe bone and ligament injuries (Figure 3). In the most severe dislocations, there is injury to the blood vessels and nerves that travel across the elbow. If this happens, there is a risk of losing the arm.

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Three bones come together to make up the elbow joint (Figure 4). The humerus bone is in the upper part of the arm and attaches to the two bones of the forearm (ulna and radius). Each of these bones has a very distinct shape. Ligaments connect all three bones together. As muscles contract and relax, two unique motions can occur at the elbow:

  • Bending occurs through a hinge joint that allows you to bend and straighten the elbow.
  • Rotation occurs though a ball and socket joint that allows the hand to be rotated palm up and palm down.

Injuries and elbow dislocations can affect either of these motions.

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Elbow dislocations are uncommon. The most common age for an elbow dislocation is 30 years old.

Mechanism of injury
Elbow dislocations typically occur when a person falls onto an outstretched hand. When the hand hits the ground, the force is sent to the elbow. Usually there is a turning motion in this force. This can drive and rotate the elbow out of its socket. Elbow dislocations can also happen in car accidents. When the crash happens, the passengers often reach forward to cushion the impact. The force sent through the arm can dislocate the elbow, just as in a fall.

Diagnosis
When the elbow is dislocated, the deformity of the arm is obvious. X-rays are the best way to confirm that the elbow is dislocated. If the bone detail is difficult to evaluate on an X-ray, sometimes a computer tomography (CT) scan will be done. If it is important to evaluate the ligaments, a magnetic resonance imaging (MRI) can be helpful. However, the doctor will set the elbow first, without waiting for the CT scan or MRI. These studies are usually taken after the dislocated elbow has been put back in place.

Risk Factors/Prevention
Some people are born with greater laxity or looseness in their ligaments. These people are at greater risk for dislocating their elbows. Some people are born with an ulna bone that has a shallow groove for the elbow hinge joint. They have a slightly higher risk for dislocation. Nothing can be done to alter these risk factors.

Symptoms
A complete elbow dislocation is extremely painful and very obvious. The arm will look deformed and may have an odd twist at the elbow. Get emergency treatment. It is important to evaluate the circulation of the arm and to check pulses at the wrist after an elbow dislocation. If the artery is injured at the time of dislocation, the hand will be cool to touch and may have a white or purple hue. This is due to the lack of warm blood getting to the hand. It is also important to check the nerve supply to the hand.

If nerves have been injured during the dislocation, some or all of the hand may be numb and not able to move. Further testing such as an X-ray is necessary to determine if there is a bone injury. X-rays can also help show the direction of the dislocation.

A partial elbow dislocation or subluxation can be harder to detect. Typically it happens after an accident, but because the elbow is only partially dislocated, the bones can spontaneously relocate and the joint may appear fairly normal. There may be pain, however. The elbow will usually move fairly well. There may be bruising on the inside and outside of the elbow where ligaments may have been stretched or torn. Partial dislocations can recur on a chronic basis if the ligaments never heal.

Treatment Options: Nonsurgical
The goal of immediate treatment of a dislocated elbow is to put the elbow back in joint. The long term goal is to restore function to the arm. First the alignment of the elbow must be restored. This can usually be done in an emergency department. The patient will receive sedation and pain medications. The act of restoring alignment at the elbow is called a reduction maneuver (Fibure 1b). This should be done gently and slowly and usually takes two people to perform.

Simple elbow dislocations are treated with early motion after a short period in a splint or sling. Keeping the elbow immobile for a long time usually results in poor range of motion for the recovered elbow. Physical therapy can be helpful during this period of recovery. Some people will never recover full elbow extension even after a course of therapy. Fortunately the elbow can work very well even without full motion. Once the elbow’s range of motion improves, the doctor or physical therapist may add a strengthening program. Interval X-rays may be necessary while the elbow recovers. This helps to ensure that the elbow joint remains well aligned.

Treatment Options: Surgical
In a complex elbow dislocation, surgery may be necessary to restore bone alignment and repair ligaments. It can be difficult to reduce the joint and to keep it in line. There is an increased risk for arthritis in the joint if:

  • The alignment of the bones is not good.
  • The elbow does not track well.
  • The elbow continues to dislocate.

After the surgery, the elbow may be protected with an external hinge. This device guards against re-dislocation. If there are associated blood vessel or nerve injuries with the elbow dislocation, multiple surgeries may be necessary. These surgeries repair the blood vessels and nerves in addition to reducing the joint. They also fix the bone and ligament injuries.

Research on the Horizon/What’s New?
Treatment for simple dislocations is usually straightforward and the results are usually good. However, many people with complex dislocations still end up with permanent disability at the elbow. Treatment is evolving to improve results for these people. The best time to schedule surgery is being evaluated for treatment of complex dislocations. For some patients with complex dislocations, it seems that a slight delay for definitive surgery may improve results by allowing swelling to decrease.

The dislocation still needs to be reduced right away, but then a brace, splint or external fixation frame may rest the elbow for about a week before a specialist surgeon attempts major reconstructive surgery.

Moving the elbow early appears to be good for recovery for both kinds of dislocations. However, early movement with complex dislocations can be difficult. Pain management techniques encourage early movement. Improved therapy and rehabilitation techniques such as continuous motion machines, dynamic splinting (spring-loaded assist devices) and progressive static splinting can improve results.

Late reconstructive surgery can successfully restore motion to some stiff elbows. This surgery removes scar tissue and extra bone growth. It also removes obstacles to movement.

Severe arthritis can develop in the elbow. For this condition, newly designed elbow replacement prosthesis can be implanted. The arthritic elbow joint can be replaced with an artificial elbow, similar to joint replacements in the hip or knee. This decreases pain and improves motion.

Ganglions (Cysts) of the Wrist

Finding a lump on your hand or wrist can be a frightening experience. But most of the time, these are harmless ganglion cysts that will often disappear in time.

Commonly, ganglion cysts grow on the top of the wrist (dorsal ganglions). But they can also be found on the underside of the wrist (between the thumb and your pulse point), at the end joint of a finger or at the base of a finger. A ganglion grows out of a joint, like a balloon on a stalk that rises out of the connective tissues between bones and muscles. Inside the balloon is a thick, slippery fluid similar to the fluid in your joints. Usually, the more active you are, the larger the lump becomes; when you rest, the lump decreases in size.

What causes ganglions
No one knows what triggers the formation of a ganglion. Women are more likely to be affected than men, and ganglions are common among gymnasts, who repeatedly apply stress to the wrist. Because the fluid-filled sac puts pressure on the nerves that pass through the joint, some ganglion cysts may be painful. Large ganglions, even if they are not painful, are unattractive. Smaller ganglions that remain hidden under the skin (occult ganglions) may be quite painful.

Examination and diagnosis
Your doctor may ask you how long you’ve had the ganglion, whether it changes in size and if it is painful. He or she may apply pressure to see if there is any tenderness, or hold a penlight up to the cyst to see if the light shines through. You will probably need to get an X-ray, so that the doctor can rule out conditions such as arthritis or a bone tumor. Sometimes, an MRI or ultrasound is needed to find a ganglion cyst hidden under the skin.

Treatment options
The first course of treatment is nonsurgical and conservative.

  • Observation. Because the ganglion is not cancerous and may disappear in time, the physician may recommend just waiting and watching to make sure that no radical changes occur.
  • Immobilization. Activity often causes the ganglion to increase in size, thus increasing the pressure on nerves and causing pain. Your physician may recommend that you wear a wrist brace or splint to relieve symptoms and allow the ganglion to decrease in size. As pain decreases, your doctor may prescribe exercises to strengthen the wrist and improve range of motion.
  • Aspiration. If the ganglion causes significant pain or severely limits your activities, you may choose to have the doctor drain the fluids with a procedure called “aspiration.” The doctor will numb the wrist and puncture the cyst with a needle to remove the fluid.

cons1_8_8These treatments leave the outer shell and the stalk of the ganglion intact, so it may reform and reappear. Outpatient surgery can remove the ganglion, but is no guarantee that the cyst will not recur. Part of the involved joint capsule or tendon sheath may also be removed.

This is of little concern, but afterwards you may feel some tenderness, discomfort and swelling. You should be able to resume normal activities in two to six weeks.

Wrist Injuries

Wrist injuries can occur during many activities. These include sports and recreation, work-related tasks, work or projects around the home, accidents and falls, and fistfights. The risk of a wrist injury is higher in contact sports such as wrestling, soccer, and football. Injuries can occur during high-speed sports such as in-line skating, snowboarding, skiing, and biking.

Wrist Sprains

The most common sporting injury to the wrist is a wrist sprain. There are many ligaments in the wrist that can be torn or stretched, resulting in a sprained wrist. This commonly occurs when the wrist is bent forcefully or in a fall onto an outstretched hand. Sprains to the wrist can range from mild to severe and are graded depending upon the degree of ligament injury that exists.

Grade 1 – mild sprain where the ligaments are stretched but not torn
Grade 2 – moderate sprain where the ligaments are partially torn
Grade 3 – severe sprains that occur when there is significant complete tearing of ligaments

With grade 1 sprains, there is some mild discomfort and decreased range of motion. With grade 2 sprains there is more serious loss of function. Grade 3 sprains result when the ligament tears away from the bone and require surgical treatment. Many times this tearing leads to a small chip of the bone being torn away with the ligament. This is known as an avulsion fracture.

The most common symptoms of a wrist sprain include:

  • Swelling of the wrist
  • Bruising or discoloration of the skin around the wrist
  • Pain at the time of the injury
  • A feeling of popping or tearing inside the wrist
  • Persistent pain when you move your wrist
  • Tenderness at the injury site
  • A warm or feverish feeling to the skin around the wrist

Most sprains can be treated with immobilization and rest. However, your orthopedic specialist may have to perform surgery to correct your wrist injury. This all depends on the severity of the sprain and intensity of the torn ligament. Surgery involves reconnecting the ligament to the bone. This procedure is followed by a period of rehabilitation with exercises to strengthen your wrist and restore motion.

Although the ligament can be expected to heal in 6 to 8 weeks, rehabilitation for a full recovery could take several months.

Other Injuries of the Wrist

Tendinosis – This is a syndrome that involves a series of very small tears (called microtears) in the tissue in and around the tendon. Common symptoms are pain, tenderness, decreased strength of the wrist, and limited movement.

De Quervain’s Tendonitis
– This can occur in the hand and wrist when the thumb extensor tendons and the sheath covering these tendons swells and becomes inflamed. This leads to pain, tenderness, and decrease in motion of the wrist.

Carpal Tunnel Syndrome – This is caused by pressure on the median nerve in the wrist. The symptoms of this syndrome include numbness, tingling, weakness, and pain in the fingers, hand and wrist areas.

Colles’ Fracture – This type of fracture is a break across the radius that occurs when the hand is extended out during a fall. The break occurs causing the wrist to become shortened and extended. Teens that enjoy outdoor sporting activities often develop these types of fractures because falls often occur.

Symptoms of a Colles’ fracture include inability to straighten the wrist or to hold heavy objects, distortion in the shape or angle of the forearm above the wrist, and pain and swelling of the injured area. Many of these fractures are not severe and you can be placed in a splint and sling. Sometimes, the orthopedic specialist applies a fiberglass cast.

More severe fractures may require surgery including placement of pins or plates and screws. Recovery from this injury ranges from 6 weeks to 6 months depending on the severity of the fracture.