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A post-traumatic painful deformity of the elbow

BMJ 2020; 371 doi: https://doi.org/10.1136/bmj.m3494 (Published 08 October 2020) Cite this as: BMJ 2020;371:m3494
  1. Tun Hing Lui, consultant1,
  2. Xiaohua Pan, professor2 3
  1. 1Department of Orthopaedics and Traumatology, North District Hospital, Hong Kong, China
  2. 2Guangdong Provincial Engineering Research Center of Wound Repair and Regenerative Medicine, Guangdong Provincial Academician Workstation of Wound repair and Regenerative Medicine, Guangdong, China
  3. 3Department of Trauma and Orthopaedics, Second Affiliated Hospital of Shenzhen University and Affiliated Baoan Hospital of Shenzhen, Southern Medical University, The 8th People’s Hospital of Shenzhen, Shenzhen, Guangdong, China
  1. Correspondence to T-H Lui luithderek{at}yahoo.co.uk

A woman in her 60s fell on her partially extended right elbow, resulting in painful deformity of the elbow with a posterolateral dimple (fig 1). She was otherwise healthy.

Fig 1
Fig 1

Deformity of the patient’s right elbow: dislocated radial head (a), olecranon (b), and tensed triceps tendon (c) resulting in a skin depression (d) just proximal to the radial head

On examination, she had no neurovascular deficit. She could not move her elbow because of severe pain in the joint and surrounding muscle guarding. The deformity was fixed (the elbow could not be flexed or extended). No bruising was visible around the elbow joint, which suggested that no substantial muscle tearing had occurred, and anteroposterior and lateral radiography (fig 2) showed no fractures. The patient received an intramuscular injection of 100 mg of tramadol hydrochloride for pain control.

Fig 2
Fig 2

Anteroposterior (A) and lateral (B) radiographs of the elbow. See answer for explanation of arrows

What is the diagnosis?

Answer

Figure 2 shows right elbow dislocation with posterolateral displacement of the radial head and proximal ulna. The arrows indicate that the radial head and greater sigmoid notch of ulna are dislocated from the distal humerus.

The dislocated radial head, olecranon, and tensed triceps tendon resulted in skin depression just proximal to the radial head (fig 1). This posterolateral dimple is typical of posterolateral elbow dislocation.

Elbow dislocation is the second most common adult joint dislocation; most are posterior or posterolateral dislocations.1

Assess radiographs for associated fractures, such as supracondylar fracture of the distal humerus, radial head fracture, and coronoid process fracture.

Extensive bruising, or the presence of a palpable gap in any of the muscles surrounding the elbow could be suggestive of muscle tear, especially the brachialis and biceps brachii muscles.

Initial management is with closed reduction. In posterior and posterolateral dislocations, the elbow is reduced by gently pushing the olecranon process back to the olecranon fossa (video). Avoid hyperextension of the dislocated elbow because it may injure (or further injure) the brachialis muscle and increase the risk of myositis ossificans.

Following reduction of a simple elbow dislocation, immediately check joint stability by assessing flexion and extension, and by calculating the degree of angulation when valgus and varus stresses are applied under fluoroscopy. Patients with moderate joint instability after reduction (>10° angulation by valgus and varus stress) have a higher incidence of stiffness or chronic instability compared with patients with slight joint instability (<10° angulation by valgus and varus stress).

Aim for early mobilisation of the joint after one week to 10 days of immobilisation. Surgery might be indicated if there is poor mobilisation of the elbow joint two to three weeks after joint reduction.

Video 1

Closed reduction of posterolateral dislocation of the elbow

Learning points

  1. Elbow dislocation is most common in the posterior or posterolateral direction.

  2. Closed reduction of posterior and posterolateral elbow dislocations is by manipulation of the olecranon process back to the olecranon fossa.

Patient outcome

Closed reduction of the dislocated elbow was performed. Immediately afterwards the elbow joint was congruent on full flexion and extension motion and, there was less than 10° of angulation by valgus and varus stress under fluoroscopy. No neurological deficit of the right upper limb was detected after the procedure.

The patient was advised to wear a hinged brace, with free movement of the elbow. The brace was removed three weeks later. She recovered fully without any stiffness, pain, or instability.

Footnotes

References

  1. ↵
    1. Robinson PM,
    2. Griffiths E,
    3. Watts AC
    . Simple elbow dislocation. Shoulder Elbow2017;9:195-204.
    OpenUrl

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