Elbow Dislocation Trauma Case for FRCS (Tr & Orth) Oral Examination
A 22-year-old man has injured his left arm in a rugby tackle. He is seen in the emergency department. These are his radiographs.
1. What do these radiographs show and how would you manage this patient?
These are plain radiographs of the elbow in a skeletally mature individual and it shows a posterior dislocation of the elbow. After completing a clinical assessment and documenting the patient's neurovascular status, I would plan to reduce the dislocation by flexing the elbow to 30 degrees in supination to unlock the olecranon from the olecranon fossa, applying longitudinal traction, and gently pushing the olecranon over the distal humerus. If this cannot be achieved, I would perform the reduction in the operating theatre under general anaesthesia. After confirming a congruent reduction, I would place the patient in an above elbow backslab, and review the patient in the fracture clinic after 1 week, where further x-rays would be taken to confirm joint stability and reduction.
The radiographs presented show a posterior dislocation of the elbow in a skeletally mature individual. After conducting a clinical assessment and confirming the patient's neurovascular status, the dislocation should be reduced, ideally under sedation in the emergency department. If this fails, an open reduction in the operating theatre under general anaesthesia may be required. After reduction, immobilization in an above elbow backslab is necessary. A follow-up appointment in the fracture clinic is particularly important to confirm joint reduction and stability, since further intervention may be necessary if the reduction cannot be maintained.
2. What structures do you think might be damaged in this injury?
For this type of injury, soft tissue stabilizers of the elbow, such as the lateral collateral ligament and the anterior capsule, are expected to be injured. The medial collateral ligament may also be damaged, and in more severe cases, the common flexor or extensor origins may be avulsed, potentially leading to gross instability.
Elbow dislocations typically involve a ring of instability, characterized by sequential tearing of the soft tissues around the elbow. In a posterior dislocation, the first structure to tear is the lateral collateral ligament (LCL), followed by the anterior capsule and then the medial collateral ligament (MCL). In this way, the lateral ulnar part of the LCL and the anterior bundle of the MCL may become damaged. In severe cases, gross instability may result if the common flexor or extensor origins become avulsed.
3. Having reduced the elbow and confirmed on x-ray that it goes back into the joint, you are unable to maintain this position because the elbow is grossly unstable. How would you manage this?
If the elbow is grossly unstable despite successful reduction, further management in the emergency department is inappropriate. The patient should be taken to the operating theatre, where I would attempt to reduce and immobilize the elbow in an above elbow backslab. If this is unsuccessful, I would explore the lateral side of the elbow to identify any tears in the LCL or common extensor origin, and if found, would repair these using suture anchors or sutures. If instability persists, the medial side of the elbow would be addressed, seeking tears to the MCL and common flexor origin through the bed of the ulnar nerve, repairing with a heavy Orthocord® #2 suture as appropriate. If gross instability persists after this, an external fixator across the elbow may be necessary.
If gross instability persists after successful reduction, further management in the emergency department should be avoided. Instead, the patient should be taken to the operating theatre where exploration of the lateral and medial sides of the elbow would be performed to identify any tears in soft tissue stabilizers. These tears may be repaired using suture anchors or sutures as necessary. If gross instability persists despite soft tissue repair, an external fixator across the elbow may be used to immobilize the joint.
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