What is Elbow Dislocation (Elbow Popped Out)?
The elbow is prone to getting dislocated more than most large joints in the body. Elbow dislocations can happen alone or along with damage to the structures that help support the elbow, and can even lead to fractures around the elbow. As a result, it’s crucial to identify and properly manage elbow dislocations to avoid complications.
In simpler terms, the elbow is the link between the lower part of the upper-arm bone (distal humerus) and the upper parts of the forearm bones (proximal ulna and radius). The elbow is made up of three separate joints. The inner side of the elbow has a joint primarily responsible for bending and straightening the arm. The outer elbow has two joints mainly responsible for rotating the arm. The unique design of the elbow allows it not only to bend and straighten but also to rotate.
The ulna, one of the forearm bones, has a unique structure that enables two joints and serves as an anchor for many structures. Notably, the anterior band of the medial collateral ligament, a key structure for elbow stability, fastens to the ulna.
The elbow is quite stable due to the fit of its joint surfaces and is bolstered by static support structures, including ligaments and the joint capsule. The muscles surrounding the joints provide active stability.
As for blood supply, the elbow houses several arteries. The brachial artery, a central component, is found at the front of the elbow and subsequently splits into the radial and ulnar artery in the proximal forearm. These arteries form a complex network surrounding the elbow.
Several nerves are present around the elbow that could be affected by an elbow dislocation. These include the radial nerve on the outer side of the arm, the median nerve, which runs along the inner side of the arm, and the ulnar nerve near the elbow. Dislocation can have a significant impact on these nerves and their functions.
What Causes Elbow Dislocation (Elbow Popped Out)?
Elbow dislocations most often occur when a person falls onto an outstretched hand. For dislocations where the elbow goes out towards the back, this usually happens due to the combined force of compression, shifting sideways pressure (valgus stress), and rotating outward (supination). Essentially, as the hand hits the ground, pressure is put on the elbow. At the same time, the body rotates externally around the hand on the ground. This movement causes a sideways shift in the elbow. For elbow dislocations where the elbow goes out towards the front, the usual cause is a fall on a bent elbow with a forward force on the upper part of the ulna bone.
During an elbow dislocation, it’s important to remember that soft tissues can also be damaged. Breakdown of supporting structures occurs from outside to inside, a process named the “Horii circle”. This disruption usually involves the lateral and medial collateral ligaments, as well as the anterior and posterior capsules.
Elbow dislocations are categorized by the direction in which the olecranon (the pointy bone at the elbow) moves relative to the humerus (the upper arm bone). Types can include posterolateral, posteromedial, posterior, anterior, medial, and lateral. Posterolateral, where the olecranon moves out and to the side, is the most common.
Meanwhile, dislocations can also be complete or partly dislocated (also known as perched). A perched dislocation means that the coronoid (part of the ulna bone) is resting on the trochlea (part of the humerus bone) instead of being fully separated like in a complete dislocation.
Lastly, dislocations can be simple or complex. A simple dislocation only involves damage to the capsule or ligaments. A complex dislocation involves breaks in the surrounding bone structure. This commonly includes bones such as the radial head, coronoid process, olecranon, distal humerus, or the medial or lateral bumps of the humerus. There’s even a type of dislocation called the “terrible triad”, which has gained its name due to consistently poor outcomes. This involves an elbow dislocation along with fractures in both the radial head and the coronoid process of the ulna.
Risk Factors and Frequency for Elbow Dislocation (Elbow Popped Out)
Elbow dislocations are the second most usual type of large joint dislocation in general, but in children, they occur more frequently than any other large joint dislocation. About 5.21 out of every 100,000 people experience an elbow dislocation each year. They occur slightly more often in males, who account for 53% of cases, compared to females who make up 47% of cases.
Young people, particularly those in their second decade of life (ages 10-19), are more likely to experience an elbow dislocation. In fact, nearly half of all the elbow dislocations occur in this age group. As people get older, they are less likely to face this problem. Most elbow dislocations occur at home, but they can also happen at work or at school.
When it comes to sports, some have a higher risk of elbow dislocations than others:
- Football is the sport with the highest number of elbow dislocations.
- Roller-blading or skateboarding comes next.
- Wrestling has the least number, compared to the others listed.
Signs and Symptoms of Elbow Dislocation (Elbow Popped Out)
When looking for signs of an elbow dislocation, the first step involves visually inspecting the elbow. Medical professionals check for any obvious misshaping or misplacement of the elbow and look for swelling under the skin. They also check the skin for any signs of bruising. By gently touching the elbow and wrist, they can check for tenderness or instability that might point to deeper issues in the elbow joint or the adjoining wrist. While carefully moving the elbow, they can get a better sense of the nature of the dislocation and look out for any signs of a fracture.
The next step is to check the blood flow and nerve functioning in the arm. While it’s rare for elbow dislocations to affect these, it’s important to check them as a precaution. This is particularly important as changes in these can happen after the dislocation has been fixed.
Testing nerve function involves different kinds of activities. For example, the median nerve (which controls some of your finger and thumb muscles) can be examined by asking the patient to make a fist. The anterior interosseus nerve (which controls certain thumb muscles) is examined by asking the patient to make an “OK” sign. The radial nerve (which helps with wrist extension and finger straightening) is examined by checking if the wrist and fingers can be extended – any inability to do so is termed as a “wrist drop”. The patient is asked to do a “thumbs up” to examine the posterior interosseus nerve, which controls some extension movements of the hand. Lastly, the ulnar nerve, which controls certain hand movements, is tested by asking the patient to spread their fingers apart and bring them together.
Testing for Elbow Dislocation (Elbow Popped Out)
Before trying to fix a dislocation, a doctor needs to know the direction of the dislocation. To determine this, they’ll usually do a simple X-ray of the elbow, which will include front-facing and sideways views. Some extra angled views of the elbow may also be taken to better understand the direction of the dislocation and to check for any nearby breaks.
After the dislocation has been corrected, more X-rays are taken to ensure that the joint is back in place correctly and to check for any associated fractures. In children, it’s very important to check for a certain type of bone entrapment in the joint. A CT scan of the elbow can also be done if the doctors need to check for more complex injuries or breaks that might be hard to see on a regular X-ray. If there are any associated fractures that are small and haven’t moved out of position, they can be treated as a simple elbow dislocation without surgery.
Treatment Options for Elbow Dislocation (Elbow Popped Out)
If someone’s elbow gets dislocated during, say, a sporting event, a skilled doctor may be able to fix it there and then, even before taking any X-rays. This process, known as reduction, can help ease pain and swelling.
Usually, the patient will be sedated and relaxed, often in an emergency department. The doctor will then adjust the position of the elbow, applying pressure to the olecranon (part of the elbow) to bring it back into its correct place. You might even hear or feel a ‘clunk’ during this process, which can suggest that the elbow is stabilised.
After the elbow has been put back in place, the doctor will gently move it around to check for stability. They will then put it in a splint to prevent movement. The elbow will typically be bent at 90 degrees in the splint. Additionally, another check will be done to make sure that there’s no damage to any arteries or nerves due to the reduction process.
If the reduction is good and the joint stable, the patient can typically avoid having surgery. They will usually have a follow-up appointment at a clinic to make sure that the reduction is holding, and also to monitor the stability of the elbow. After about two weeks, if the joint is still stable, the splint can be removed, and physical therapy, including range of motion exercises, can begin. But if the elbow is less stable, the splint will stay on, and the patient might start using a different type of splint that allows some movement.
Surgery is only usually necessary in a few situations. For instance, if the elbow cannot be reduced, or if it’s still not stable after reduction. Also, if there are any broken bones that are unstable because of the dislocation, or if there are trapped fragments or an entrapped medial epicondyle (a part of the elbow bone), surgery will be needed. The type of surgery will depend on the complexity of the dislocation, any instability, and the extent of any soft tissue damage.
What else can Elbow Dislocation (Elbow Popped Out) be?
Elbow dislocations are typically diagnosed through X-rays. As part of the process, the doctor would feel around the patient’s elbow and surrounding bones to check for any pain. Pain in this area could be a sign of different types of fractures. There could also be injuries to the ligaments around the elbow, which may cause the elbow to become unstable.
Elbow dislocation can turn chronic if the elbow stays dislocated for more than two weeks. If there’s a history of instability, past attempts of adjusting the elbow back into place or repeated dislocations, that might indicate this is a chronic condition. About 15% of patients with chronic dislocations might experience a temporary loss of sensation or movement in their arm due to compression or damage of the ulnar nerve. Over time, this could cause the surrounding structures to become fibrous, making it harder to adjust the dislocation. And in these cases, doctors often have to resort to surgery.
During the operation, the surgeon would remove the fibrous and granulated tissue that’s formed within the joint. They might also need to loosen the tight capsular structure surrounding the joint from the front and back. In some cases, a procedure to extend the length of the triceps (the muscle at the back of the arm) might also be necessary. The surgeon might also need to relocate the ulnar nerve to a different position to prevent further complications.
What to expect with Elbow Dislocation (Elbow Popped Out)
It’s not rare for patients to lose 10 to 15 degrees of motion towards straightening the elbow fully. Keeping the period of non-movement under three weeks can help avoid stiffness or tightness in the joint, known as contracture. If the recovery is slower than expected, dynamic elbow braces along with physical therapy can be used. It can take patients up to 5 months to regain full motion in the elbow. If these treatments are not effective, a surgical procedure to release the tightness may be needed.
In children, the outlook after an elbow dislocation is generally brighter. Kids typically have lower instances of contracture and loss of movement, and they are more likely to regain normal elbow function.
Possible Complications When Diagnosed with Elbow Dislocation (Elbow Popped Out)
Elbow injuries can lead to several complications. One of the most common is a loss of range of motion. This is often due to the length of time the elbow is immobilized in a cast or splint. Specifically, if the elbow is immobile for over 25 days, you could lose up to 30 degrees in extension and nearly 20 degrees in flexion. This could be caused by stiffening of the front of the joint capsule, the surrounding ligaments, and muscles, or by internal factors like irregularities in the joint or fragment blocking motion.
Another common complication is abnormal bone formation around the joint, although this usually doesn’t impact movement. A condition called myositis ossificans can cause calcium to build up in the soft tissues and muscles around the joint, but it rarely restricts motion. There are some risk factors for abnormal bone formation, such as being a male over the age of 60, having a burn injury, or having certain genetic disorders. Preventive measures for high-risk patients can include taking nonsteroidal anti-inflammatory medications (NSAIDs) or receiving low-dose localized radiation. If these methods aren’t successful, the abnormal bone growth might have to be surgically removed.
Elbow instability is another common outcome after an elbow injury. Depending on the nature of the injury, different ligaments may be affected, requiring appropriate treatment. Lateral instability is quite common and can be addressed with specific positionings in the cast or splint. In some cases, a surgical intervention might be necessary to repair the elbow dislocation or associated fractures.
Though uncommon, nerve or artery injuries can occur from acute elbow dislocations. One of the most frequently reported is damage to the ulnar nerve; however, this usually resolves after the elbow has been moved back into place. Other nerve injuries, like those to the median and anterior interosseous nerves, are less common but can occur. A sustained lack of pulse or blood flow in the arm could suggest a vascular injury, which calls for medical emergencies. Pulse usually returns after the elbow is put back in place.
Preventing Elbow Dislocation (Elbow Popped Out)
Certain activities can increase the risk of elbow dislocations because of the type of stresses they put on the body. These include sports like football, roller-blading or skateboarding, and wrestling. It’s important that individuals participating in these activities take precautions, wear protective gear, and if they can, try to avoid placing too much strain on these susceptible body areas.
A common outcome after an elbow dislocation is a slight decrease in the range of motion, typically losing about 10-15 degrees of full extension. It’s important to be aware of this early on and to start working on improving your flexibility as soon as you’re allowed to.
Furthermore, elbow dislocations are the most frequent type of large joint dislocation found in children. The excellent news is that children usually recover a better range of motion and elbow functionality than adults. However, parents need to be aware of potential growth issues that can occur.
