REDUCING A DISLOCATED ELBOW

The sooner you do this, the easier it will be, and the fewer the complications. If it is very recent, the alternative method described below may work.

Check the patient’s radial pulse, and his median, ulnar, and radial nerves (Fig. 75-3).

ANAESTHESIA Good relaxation is essential in adults, but is less necessary in children. (1) General anaesthesia. (2) Give a child ketamine (A 8.2) or a general anaesthetic. (3) Axillary (A 6.18) or brachial plexus blocks are satisfactory if you do them well.

REDUCTION lie the patient on his back with his upper arm vertical, and his forearm flexed across his chest, as in A, Fig. 72-6.

Find an assistant and ask him to exert traction on the patient’s hand from the other side of the table (1), and at the same time, to flex the elbow gradually (2). While he does this, grasp the patient’s elbow in both hands, with your fingers round the front of his humerus, and your thumbs behind his olecranon, then push it forwards (3).

The patient’s olecranon should lie in the centre of his arm midway between his two epicondyles as in A, Fig. 72-2. If it is shifted sideways, first move it into the midline with your thumbs as you reduce it, then push it forwards over the lower end of the humerus. The dislocation will reduce with a scrunch.

When you think that you have succeeded, move the patient’s elbow through its normal range. Unless you can get full flexion, you have not reduced it. If it feels stable, treat it as described below.

ALTERNATIVE METHOD If the dislocation is very recent, method B, in Fig. 72-6 may work without an anaesthetic.

Sit the patient sideways on a chair. Put a pillow over the top of the chair’s back, and let his forearm hang over it.

Ask an assistant to exert traction on the patient’s wrist, while at the same time you press on the back of his olecranon. Using the same movements described above, you may be able to coax his olecranon back into place.

Alternatively, and with experience, you may be able to caress his elbow and then suddeny flick it into place before he knows what has happened, and without using an anaesthetic.

X–RAYS Check: (1) that reduction is satisfactory, and (2) that there is no bony fragment trapped in the joint. If there is, it will have to be removed by opening the joint. If you are not able to do this, refer the patient.

CAUTION! if you neglect to X–ray a patient after trying to reduce his dislocated elbow, you may fail to diagnose that reduction is incomplete, until after the swelling has gone. Reduction will then be possible only at open operation.

POSTOPERATIVE CARE FOR A DISLOCATED ELBOW

As soon as a patient recovers from the anaesthetic, reexamine his radial pulse, and his median, ulnar, and radial nerves to make sure that you have not injured them during reduction.

If reduction is stable, rest his arm in a sling for 3 weeks in the hope of avoiding post– traumatic ossification. While it is in the sling he should move it as much as possible. Start shoulder, finger, and wrist exercises within the sling immediately. Don’t let him take the sling off for 3 weeks. If there are no complications, his elbow will recover slowly, but he may always have some limitation of full extension.

CAUTION! Never perform passive stretching exercises. These encourage post–traumatic ossification.

If reduction is unstable, flex his elbow as far as it will go in a collar and cuff sling, or with a posterior slab, for 3 weeks. Then start active movements.

If reduction is very unstable in all directions: (1) there is a fracture, or (2) his medial epicondyle is trapped inside his elbow (see below), or (3) his ligaments are torn. Apply a temporary plaster backslab and refer him.

DIFFICULTIES WITH A DISLOCATED ELBOW

If the patient’s dislocation occurred MORE THAN TWO WEEKS AGO, every day’s delay will have made the prognosis worse. If the dislocation occurred less than 6 weeks ago, try to reduce it by manipulation. If it is already 2 weeks old, this will be difficult. If you fail, refer him for open reduction. An arthrodesis or elbow excision may be necessary.

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Figure 72.6: TWO WAYS OF REDUCING A DISLOCATED ELBOW. If a dislocation is very recent, method B may work without an anaesthetic. Sit the patient sideways on a chair. Put a pillow over the top of the chair’s back, and let his forearm hang over it. Kindly contributed by John Stewart.

If his dislocated elbow has been INCOMPLETELY REDUCED: (1) A child’s medial epicondyle may have broken off and be inside the joint. If you are in doubt, X–ray his other elbow, and look for a small centre of ossification in an abnormal position. (2) There may still be a sideways displacement after the backward displacement has been corrected. If so, try to reduce the dislocation again. If you fail, refer him without delay because there is probably soft tissue between the joint surfaces.

If the patient’s elbow REDISLOCATES EASILY and is very unstable, make sure there are no fractures. Apply a collar and cuff to maintain the stable position for 2 weeks. If it still redislocates, refer him.

If his MEDIAL EPICONDYLE IS TRAPPED inside his elbow, he is likely to present as failure to reduce a dislocation and a very unstable elbow. A trapped medial epicondyle is easy to find because the flexor muscles are attached to it. If it really is in his elbow joint and his elbow is unstable in all directions, apply a temporary posterior slab, and refer him.

If he has OTHER FRACTURES, he may have a flake off his capitulum, or a fracture of his coronoid, or a fracture of the head of his radius. First reduce the dislocation, and then treat the fracture as if the dislocation had never existed. If it is a major flake, refer him immediately to have it removed.

If a NERVE HAS BEEN INJURED, particularly his ulnar nerve, it may need to be explored by an expert if it does not recover spontaneously in a month. Any of the nerves crossing the elbow may be injured, especially the ulnar.

If 2 or 3 weeks after an injury the MOVEMENT OF A PATIENT’S ELBOW BECOME LESS, a firm mass forms near the joint, and his soft tissue starts to calcify, he is suffering from POST TRAUMATIC OSSIFICATION (myositis ossificans). When an elbow dislocates the periosteum is torn off the back of the humerus and brachialis is torn from the front. These injured tissues may calcify and ossify, particularly in children. The same complication can follow a supracondylar fracture, and is made worse by: (1) repeated manipulations in an attempt to reduce the injury, and (2) forceful movements subsequently.

Watch the patient carefully for the first few weeks after reduction. If at any time movement of his elbow becomes less, stop him moving it for a few days. Continue to immobilize it, until unrestricted use of it no longer diminishes its range. Allow him full activity, but avoid forced movements and exercises. The only safe movements are those that are possible using the injured elbow’s own muscles, without the help of his normal hand. X–ray his elbow and look for soft tissue calcification, usually anteriorly in brachialis. See also Section 72.10.

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Figure 72.7: SUPRACONDYLAR FRACTURES. A, posterior displacement is much more common. B, in an anterior displacement a line down the front of the humerus passes behind the distal fragment.

Don’t try to remove any bony lumps or refer him for their removal until at least a year after the injury. Sometimes, in spite of the best care, a patient’s elbow becomes stiff permanently. If this starts to happen, keep it in its most useful position, according to his needs. This is usually flexed to about 90\ensuremath{^\circ }, with his forearm in mid–pronation (Fig. 73-1).

AVOID FORCED ELBOW MOVEMENTS