13
ELBOW DISLOCATION: ACUTE AND
CHRONIC MANAGEMENT INCLUDING
ASSOCIATED FRACTURES
SCOTT F.M. DUNCAN
ANDREW J. WEILAND
MECHANISM OF INJURY
During a fall on an outstretched hand, the elbow is extended
and the arm abducted, resulting in dislocation of the joint.
There is damage to the anterior capsule and the brachialis
muscle, and sometimes there is an associated fracture or
fractures. This force can continue to result in tearing of the
capsular epicondylar attachments and collateral ligaments.
These forces can result in injury and fracture to the radial
head, radial neck, coronoid process, olecranon, or capi-
tellum.
The forces acting on the joint during dislocation are ten-
sile, compressive, and shear. Tensile forces disrupt the liga-
mentous restraints, whereas compressive and shear forces
act on the articular surfaces. Therefore, fractures of the ra-
dial head and neck, as well as the capitellum, are common
(1,2). Chondral injuries to the capitellar and trochlear sur-
faces are more common than x-rays would suggest (3,4).
Having an appreciation for how the elbow dislocates helps
with understanding the classification, clinical examination,
radiographic interpretation, treatment plan, and possible
complications.
A posterolateral dislocation occurs with tearing of the
radial collateral ligament and lateral capsule (5). As the
elbow hyperextends, the capsular constraints are torn, forc-
ing the humerus through the anterior capsule and injuring
the brachialis muscle. The anterior oblique ligament is the
primary stabilizer in resisting valgus forces; however, this
provides a pivot point that allows the radius and ulna to
dislocate posteriorly if the lateral ligaments are damaged (5).
This can result in a posterolateral (Fig. 13.1A and B), pure
posterior, or posteromedial (Fig. 13.1C) dislocation. An an-
terior dislocation occurs when extreme hyperextension oc-
Hospital for Special Surgery, New York, New York 10021.
curs, often resulting in brachialis and neurovascular injury.
The anterior dislocation can be caused by a direct blow to
the olecranon and the soft tissue injury is usually quite se-
vere. Pure lateral dislocations are associated with severe tear-
ing of the medial elbow ligaments. Conversely, in the rare
medial elbow dislocation, the lateral ligaments are primarily
torn. In a divergent dislocation, the radius separates from
the ulna with tearing of the interosseous membrane, annular
ligament, and distal radioulnar joint capsule (Fig. 13.2).
Elbow dislocation without fracture occurs by a mixture of
forces that load the joint and then place varus or valgus
forces that uncouple the olecranon from the trochlea, which
allows the joint surfaces to disengage.
Two theories have been advanced to elucidate the mecha-
nism of elbow dislocations. The hyperextension theory
holds that a direct loading force is placed on the hand while
the elbow is extended (6,7). The olecranon impinges on its
fossa, levering the ulna and radius and tearing their capsular
restraints and sometimes avulsing or shearing off the coro-
noid process. With this injury, the brachialis is also torn.
As extension forces continue, epicondylar attachments of
capsule and ligaments tear, resulting in dislocation. An ab-
duction force can complete the dislocation or cause injury
to the radial head or capitellum. The second theory holds
that elbow dislocations occur with the elbow slightly flexed
and then an axial loading force is applied (8). The lateral
capsule and radial collateral ligament then tear and result
in a posterior dislocation. O’Driscoll et al. (9) have proposed
that a varus stress with the elbow in extension can disrupt
the lateral ligament complex, resulting in a perched disloca-
tion. Additional force causes rotation of the forearm,
thereby completing the dislocation (Fig. 13.3) (9).
In persons who have undergone surgical exploration just
after sustaining a posterior dislocation, most have ruptured
the medial collateral ligaments and some have also ruptured
192 The Athlete’s Elbow

B,C
FIGURE 13.1. A: Illustration of a posterolateral dislocation. (From Chapman MW. Operative or-
thopaedics, 2nd ed. Philadelphia: JB Lippincott Co, 1993, with permission.) B: Anteroposterior
radiograph view of a posterolateral dislocation. C: Anteroposterior radiograph view of a postero-
medial dislocation. (From Hotchkiss RN. Fractures and dislocations of the elbow. In: Rockwood and
Green’s fractures in adults, 4th ed, New York: Lippincott Williams & Wilkins, 1996, with permission.)

the origin of the flexor-pronator mass from the medial epi-

FIGURE 13.2. Divergent dislocation. (From Chapman MW. Oper-
ative orthopaedics, 2nd ed. Philadelphia: JB Lippincott Co, 1993,
with permission.)
condyle (Fig. 13.4) (10–13). Josefsson et al. discovered that
the medial collateral ligament was disrupted in every case
of elbow dislocation that they surgically explored. At the
same time, they explored the lateral side and found the
lateral ligaments also torn in all cases (11). Disruption of
the anterior bundle of the medial collateral ligament is con-
sidered the site of pathology (14,15). The finding that com-
plete dislocation tears both collateral ligament structures is
supported by the observation that calcification is frequently
seen in these ligaments (7,11,16,17).
If the radial head remains dislocated after an attempted
reduction of an elbow dislocation, then one must consider
a congenital or developmental dislocation in the setting of
acute trauma. Evaluation of the contralateral elbow can be
helpful, given that such conditions are frequently bilateral.
Throwing sports can over time cause subtle elbow instability
that interferes with function on the field, but these usually
do not result in gross dislocation.
An acute elbow dislocation is an orthopedic emergency
and once the condition is recognized, it should be quickly
reduced. Chronic dislocations are not emergent so long
as the neurovascular status of the hand and forearm is
normal.

FIGURE 13.3. Proposed mechanism of elbow dislocation during
a fall. (From O’Driscoll SW, Morrey BF, An KN. Elbow dislocation
and subluxation: a spectrum of instability. Clin Orthop 1992;280:
186, with permission.)
FIGURE 13.4. Ligamentous injury after dislocation. (From Chap-
man MW. Operative orthopaedics, 2nd ed. Philadelphia: JB Lip-
pincott Co, 1993, with permission.)
13. Elbow Dislocation 193
INCIDENCE
The incidence of elbow dislocations has been variably re-
ported as highest among 10 to 20 year olds and 30 year
olds (18). In children younger than 10, elbow dislocation
is the most common major joint dislocation seen (19).
Sporting accidents, falls (elderly), and motor vehicle acci-
dents have all been noted to be mechanisms for elbow dislo-
cation. The elbow is the second most common major joint
to dislocate; the shoulder is the most common site of dislo-
cation (20). The elbow joint is quite constrained compared
to other joints in the body, giving it great stability. Despite
this, dislocation is still frequently seen in both low-energy
and high-energy trauma. Fortunately the intrinsic stability
of the elbow reduces the occurrence of redislocation once
reduction is performed and bony and soft tissues have
healed.
Elbow dislocations represent from 10% to 25% of all
elbow injuries (21). The nondominant upper extremity is
affected in approximately 60% of cases. This injury occurs
two and a half times more frequently in men than in women
and has a comparable ratio in adults and in children (16,
18). Approximately 40% occur during sports, 10% from
traffic accidents, and 50% from falls or other causes (18).
Demographic studies estimate that about 6 of every 100,000
persons will sustain an elbow dislocation (22).
CLASSIFICATION
Based on the modification of Hamilton’s and Stimson’s
classification systems, elbow dislocations are divided into
anterior and posterior dislocations (Fig. 13.5) (23). Poste-
rior dislocations are subdivided into posterior, posterolat-
eral, posteromedial, and pure lateral based on the position
of the olecranon in reference to the distal humerus. Posterior
or posterolateral dislocations constitute 90% of elbow dislo-
cations. Pure lateral dislocations are less frequent and pos-
teromedial are quite uncommon (15). Anterior dislocations
are also quite rare, occurring in only 1% to 2% of cases
(16). A prominent olecranon tip and a shallow fossa may
predispose patients to this type of dislocation (24). Pure
medial and divergent dislocations are extremely uncommon
and usually require open reduction in our experience be-
cause of trapped muscle and/or nerve. Unreduced and recur-
rent dislocations are classified separately because they re-
quire completely unique treatment algorithms.
Morrey and O’Driscoll use a different classification sys-
tem in which they categorize between complete or perched
dislocation. In this system, a complete dislocation simply
has the ulna behind the humerus. A perched dislocation has
the elbow subluxated, but the coronoid appears impinged
on the trochlea.
194 The Athlete’s Elbow
FIGURE 13.5. The five types of elbow dislocation determined by the direction of the forearm
bones in relation to the humerus. (From Browner BD, Jupiter JB, Levine AM, et al. Skeletal trauma.
Philadelphia: WB Saunders, 1998, with permission.)
PHYSICAL FINDINGS
Patients usually present immediately after sustaining an
acute injury with severe pain and supporting the injured
arm with the contralateral hand. The forearm is shortened
with the olecranon and radial head projecting posteriorly
(in posterior dislocations). Characteristically they have soft
tissue swelling and obvious deformity about the elbow. Be-
fore any attempt at joint reduction, a thorough neurovascu-
lar examination should be completed and documented. As
per any orthopedic examination, the joints above and below
the level of injury should be examined. Thus, the shoulder
and wrist are examined to rule out any concomitant injury,
which is reported in 10% to 15% of patients (20). This
includes evaluation of the distal radioulnar joint and the
interosseous membrane to rule out a variant of the Essex-
Lopresti injury.
Vulnerable structures include the brachial artery, median
nerve, and ulnar nerve. Brachial artery and median nerve
injuries are more common in the anterior dislocation. How-
ever, any of these structures can be injured or entrapped
from reduction maneuvers. The mechanism for this is dis-
cussed later. If there is any unease about the amount of
swelling, vascular injury, or potential for compartment syn-
drome, the patient should be admitted for observation.
RADIOGRAPHIC FINDINGS
Anteroposterior and lateral radiographs are the minimum
set of films that need to be obtained. Frequently, oblique
views are needed to assist in determining the direction of
dislocation and to identify any periarticular fractures. Spe-
cifically, the distal humerus (particularly medial epicon-
dyle), radial head, and coronoid process are vulnerable to
injury. If the dislocation is irreducible, close attention
should be paid to see whether the medial epicondyle has
fractured and is blocking the reduction. An arteriogram
should be obtained immediately if a vascular injury is sus-
pected.

ASSOCIATED INJURIES
Unfortunately associated injuries with elbow dislocation are
relatively common (25–28). Avulsions from either the me-
dial or the lateral epicondyles occur in roughly 12% of dislo-
cations (Fig. 13.6). Coronoid fractures are found in approxi-
mately 10% of cases, as are olecranon fractures, and radial
head and neck fractures occur in 5% to 10% of cases
(25–28). Interestingly, 10% of patients with a radial head
or neck fracture have a concomitant elbow dislocation. Os-
teochondral lesions from elbow dislocations are likely more
prevalent than x-rays would allow us to diagnose. Capi-
tellum osteochondral injuries are quite common given the
shear force type loading that occurs during dislocation.
About 12% of patients have injuries at other sites besides
the elbow (29–31). These other associated injuries include
shoulder injuries, perilunate dislocations, distal radius frac-
tures, and ulnar styloid fractures.
Compartment syndrome is a known risk with elbow dis-
locations. Because of the severe soft tissue damage that re-
sults in significant swelling, compartment syndrome can
result. A constricting effect is caused by the intact structures
such as the forearm fascia, biceps tendon, and lacertus fibro-
sus, which results in elevated compartment pressures. A
Volkmann ischemic contracture can be the end result and
compartment syndrome should be quickly differentiated
from isolated neurologic injuries.
FIGURE 13.6. Medial epicondyle avulsion fracture after elbow
dislocation. This infrequently can become trapped in the joint,
requiring surgical intervention. (From Chapman MW. Operative
orthopaedics, 2nd ed. Philadelphia: JB Lippincott Co, 1993, with
permission.)
13. Elbow Dislocation 195
Brachial artery injury has been associated with elbow
dislocations (32–41). Although ligation of the injured arter-
ies has been advocated in the past (32–41), current literature
clearly recommends arterial repair with or without vein
grafting (28,32,33,37,39,41–46). Anatomic studies have
shown that much of the collateral circulation is interrupted
at the time of dislocation, thus questioning the role of liga-
tion in these injuries.
Absence of a viable pulse does not preclude emergent
reduction of an elbow dislocation. The patient should be
taken immediately to surgery with the plan of performing
an arterial reconstruction if arterial flow is not reestablished
after reduction of the elbow and the hand continues to be
poorly perfused. Time should not be wasted in an angiogra-
phy suite. Only after the vessels have been exposed should
an intraoperative arteriogram be considered. If more than
4 hours of ischemic time has passed, then forearm fascioto-
mies are mandatory to reduce the possibility of postperfu-
sion compartment syndrome and a subsequent Volkmann
contracture. Even if pulses are good before reduction, inti-
mal injuries can still threaten hand perfusion. Surgeons
should be vigilant in their examination for possible com-
partment syndrome. Pain with passive extension of the fin-
gers is the most common sign of ischemia. Injury to the
anterior interosseous, median, radial, and ulnar nerves have
all been reported. However, the least likely of these to be
injured is the radial nerve (47).
TREATMENT
The dislocated elbow should be treated promptly and atrau-
matically. Numerous techniques for reduction have been
described in the literature. One consensus remains, how-
ever: They all require correction of medial or lateral dis-
placement first, followed by forearm traction. To reduce the
elbow, sufficient muscular relaxation is a necessity. General
anesthesia with muscle relaxation is commonly used, partic-
ularly if the dislocation happened several hours previously
because the amount of swelling and muscle spasm can be
severe by that point.
Various techniques of reduction have been described
(48–51). One is the placement of a patient in the prone
position with the elbow flexed at 90 degrees and then apply-
ing a 10-lb weight to the hand and letting gravity reduce
the elbow joint (50). Parvin and Quigley have discussed
various techniques of placing the patient prone with the
surgeon or weights hanging from the arm to facilitate reduc-
tion (50,51). A similar method in which the arm is hung
over the back of a chair has been proposed by Lavine (49).
We do not advocate these techniques.
Our preferred technique is extending the elbow and pro-
viding countertraction on the upper arm and maneuvering
the olecranon distally and anteriorly with the thumb. This
allows the coronoid to clear the trochlea (7,52). Force is
196 The Athlete’s Elbow
FIGURE 13.7. Technique for elbow reduction. (From Browner BD, Jupiter JB, Levine AM, et al.
Skeletal trauma. Philadelphia: WB Saunders, 1998, with permission.)
applied to the olecranon, pushing it distally and over the
trochlea. Before traction is applied, lateral or medial dis-
placement needs to be corrected first so that the risk of
median nerve entrapment within the elbow joint is dimin-
ished (53). After displacement has been corrected, the fore-
arm is supinated. With the patient’s elbow mildly flexed,
longitudinal traction is applied and the surgeon’s thumb is
used to push the olecranon forward over the trochlea (Fig.
13.7). If a ‘‘clunk’’ is felt during the reduction. this usually
means the elbow will be stable to range-of-motion testing.
Multiple reduction attempts should be avoided because this
will further traumatize the soft tissues, predisposing to het-
erotopic ossification (54). There is controversy whether hy-
perextension is truly needed to unlock the olecranon from
the distal humerus. Hallett (55) and Matev (53) have writ-
ten about median nerve entrapment after hyperextension
has been used to reduce elbow dislocations. Loomis believes
that hyperextension results in greater injury to the brachialis
muscle (56).
Postreduction anteroposterior and lateral views are man-
datory. Attention should be paid to ensure the reduction is
concentric and there are no associated fractures with possi-
ble loose bodies in the joint. If fluoroscopic imaging is avail-
able, this can be useful in providing stress views after reduc-
tion is completed. We take the elbow through a complete
range of motion without any varus or valgus stressing to
check uniplanar stability. If redislocation occurs in exten-
sion, this usually indicates that the elbow is unstable. Most
postreduction elbows are unstable with valgus stress when
the forearm is pronated. The hand should be left free in
the splint so it can be frequently checked in the immediate
postreduction period. Capillary refill should be assessed in
the volar fingertips and not the nail beds. If the joint is
concentrically reduced and stable to range of motion, it is
then splinted at 90 degrees of flexion for approximately 1
week (plus or minus 3 days). A stiff elbow will result from
more than 2 weeks of splinting. More than 3 weeks of im-
mobilization has been well documented to result in poor
outcomes (21,57).
Any widening of the postreduction joint spaces can sig-
nify entrapped osteochondral fragments, entrapped soft
tissue structures, or posterolateral rotatory instability. If
entrapped osteochondral fragments or neurovascular struc-
tures are trapped within the joint, surgery is required to
remove or free them from the joint. Irreducible acute elbow
dislocations are uncommon (58). An associated fracture is
usually the culprit in irreducible dislocations (59). For ex-
ample, the radial head has been demonstrated to be caught
in the forearm soft tissue or buttonholed through forearm
fasciae in cases of irreducible dislocations (60,61). Reduc-
tion is accomplished by surgical release. Routine repair of
the medial collateral ligament, which has been advocated
 13. Elbow Dislocation 197

by some (14), has not demonstrated any long-term advan-

tage (11). Open reduction may be necessary for an elbow
dislocation that has been out for more than 10 days and
that fails closed reduction attempts (62). The annular liga-
ment or a collateral ligament can uncommonly prevent re-
duction by interposing in the joint (58,60,61).
Maintenance of reduction and joint congruency should
be documented radiographically at 3 to 5 days postreduc-
tion and again at 10 to 14 days postreduction (11). Despite
the best molded cast or splint, unstable elbows are particu-
larly prone to redislocation and need to be rechecked fre-
quently. Protzman (63) reported his West Point experience
in athletes recommending minimal immobilization (less
than 3 weeks). Mehlhoff et al. have also found this to be
true and recommend motion within the first week (21,63).
O’Driscoll and Linscheid (64) currently advocate gentle ac-
tive motion in the first week as well. By 3 months, most
patients should regain 80% to 90% of normal function
(65).
If the elbow tends to subluxate or dislocate in extension,
the amount of extension should be noted. The forearm
should then be pronated to see if the instability in extension
is prohibited by this forearm position. If this maneuver sta-
bilizes the elbow in extension, then the anterior band of the FIGURE 13.8. Heterotopic ossification in the brachialis.
medial collateral ligament is intact. The elbow can then be
placed through the full range of motion so long as the brac-
ing system keeps the forearm pronated. If the elbow is still
unstable in extension, the forearm should be placed in neu- SPECIAL TECHNIQUES FOR RARE TYPES OF
DISLOCATION
tral rotation with an extension block at the level of stability.
This can gradually be increased during a 3-week period. Anterior dislocations are reduced by gentle traction, followed
A hinged elbow brace is then used while range-of-motion by pressure placed posterior and downward on the forearm,
exercises are started. If this is not available, interval splinting and force applied to the anterior distal humerus. Mild flexion
can be substituted. For those elbows that feel unstable in of the forearm unlocks the olecranon from its location ante-
terminal extension, the hinged brace can be locked at 20 rior to the trochlea. The surgeon should test active extension
degrees; if this is not available, an orthosis with an extension of the elbow because the triceps insertion can be torn and sep-
block or a cast brace can be substituted. Supination and arated in this type of injury. We usually splint the elbow in
pronation should be part of the rehabilitation program and slight extension (i.e., 70 degrees of flexion).
initiated at the same time as elbow range of motion. During Care should be taken not to convert medial or lateral
the next 3 to 6 weeks, extension is gradually but continu- dislocations into a posterior dislocation during reduction
ously increased. Almost full motion should be achieved by attempts. These types of dislocations are best reduced with
6 to 8 weeks; if not, then static extension and flexion splints the elbow in mild extension and traction on the forearm;
can be used to try to gain further motion. Active range-of- a medial or lateral force is then applied.
motion exercises may be done under the supervision of a In the divergent elbow, dislocation reduction is facili-
therapist. However, we instruct the therapists not to perform tated by reducing the ulna first—similar to the technique
any passive range of motion about the elbow because of the described for posterior dislocations. However, while the
ulna is undergoing manipulation, force is applied over the
risks of heterotopic ossification. Small amounts of hetero-
radial head to reduce it at the same time. Pronation of the
topic ossification are not uncommon and are usually seen forearm reduces the divergence of the radius and ulna. If
in the brachialis (Fig. 13.8), as well as in the medial and the radial head will not reduce, surgical reduction may be
lateral ligaments. This is rarely clinically significant (66). required. For this type of injury, we immobilize the elbow
However, we routinely place our patients on indomethacin in full supination and 90 degrees of flexion (67).
75 mg (preferably the sustained-release version) if they do Morrey has described a different treatment for the
not have any contraindications to nonsteroidal antiinflam- perched dislocation. He recommends using an analgesic,
matory drugs. intraarticular lidocaine (Xylocaine), and manipulating the
 198 The Athlete’s Elbow
elbow by placing pressure over the olecranon with the elbow
extended and axial distraction.
SURGICAL INDICATIONS
Prospective studies have not demonstrated an advantage to
early collateral ligament repair over early motion for simple
elbow dislocations (10,11). However, there are two circum-
stances in which surgery is indicated for acute elbow disloca-
tions. One is when the dislocation has associated displaced
or unstable fractures involving the elbow joint. The second
instance is when flexion is required beyond 50 degrees to
60 degrees to keep the joint reduced. Recurrent instability
occurs in 1% of patients with simple elbow dislocations
(10,11,21). Both collateral ligaments and secondary elbow
stabilizers are disrupted in these injuries. The medial liga-
ments are the primary stabilizers of the ulnohumeral joint
(20), whereas the lateral ligaments prevent the elbow from
subluxating posteriorly and rotating away from the humerus
in supination (68). Posterolateral rotatory instability can be
seen as posterior translation of the radial head on lateral
elbow films. Elbow stability and function is really depen-
dent on both sets of collateral ligaments and an intact coro-
noid process.
The extensor and flexor origins, as well as the ligament
A,B
complexes, are usually found to be torn in cases of persistent
instability not associated with fracture. Approaching the
medial side first, the ulnar nerve is identified and protected.
Next, the torn flexor-pronator mass and medial collateral
ligament are identified and reattached to the medial epicon-
dyle with suture anchors. A Kocher approach can be used to
expose the torn extensor origin and lateral elbow ligaments,
which can also be reattached with suture anchors.
We begin early protected motion with these injuries if
a stable elbow results from our repair. If the elbow continues
to be unstable despite our best attempts at repair of both
bony and soft tissues, we apply a dynamic external fixator.
Rigid external fixation with pins placed in the humerus and
ulna should be a secondary choice when a dynamic system
is not available. Dynamic systems can be challenging to
apply and can be associated with significant complications.
They should be used only by surgeons familiar with these
techniques. At no time are transarticular pins appropriate
given their problematic history of articular damage, chon-
drolysis, and pin breakage. Furthermore, in treating the un-
stable elbow, there is no roll for casting or splinting because
the elbow can dislocate within these devices.
The obvious advantage of a dynamic external fixator is
the ability to begin joint motion while still protecting any
repairs (Fig. 13.9). We usually leave these on for 4 to 6
weeks. Static external fixation should not be left on for more
FIGURE 13.9. Anteroposterior view
(A) and lateral view (B) of dynamic ex-
ternal fixator for unstable elbow dislo-
cation. (From Thompson HC, Garcia A.
Myositis ossificans: aftermath of
elbow injuries. Clin Orthop 1967;50:
129–134, with permission.)

than 3 to 4 weeks. A concentrically reduced elbow joint
with residual stiffness secondary to immobilization is prefer-
able to recurrent joint instability. A secondary capsular re-
lease procedure can be done later to correct the residual
stiffness.
Comminuted or unstable fractures, coupled with elbow
instability, should be fixed operatively, ideally within 24
hours to minimize the amount of swelling that must be
operated through. Fractures that do not jeopardize elbow
joint congruity and stability do not necessarily require surgi-
cal intervention.
The Kocher approach is used to expose the radial head
and perform any needed repairs. The interval is between
the anconeus and the extensor carpi ulnaris. The supinator
is then identified over the lateral collateral ligament. An
incision anterior to the midline of the radial head is made
through the collateral and annular ligament complex. This
Neutral
Supination
13. Elbow Dislocation 199
preserves the posterior fibers of the lateral collateral ligament
complex, making a subsequent repair easier. Dissection is
done with the arm fully pronated to protect the posterior
interosseous nerve. When retracting around the radial neck,
care should be taken to avoid injuring the posterior interos-
seous nerve. Provisional fixation with K wires is often
needed to hold reduction of radial head fractures while the
permanent hardware is placed. Accutrak screws, Herbert
screws, or Minifragment screws can be used to fix these
fractures (the surgeon should use the more familiar system).
A safe zone for screw and plate placement has been described
by Smith and Hotchkiss (Fig. 13.10) (69). The area that is
nonarticular is where hardware should be placed and this
comprises 90 degrees of the radial head circumference.
Excision of the capitellum or radial head after an elbow
dislocation is best avoided, except in cases in which it does
not compromise stability (70,71). However, when the radial
"Safe zone"
FIGURE 13.10. Radial head and neck safe
zone for internal fixation. (From Smith GR,
Hotchkiss RN. Radial head and neck frac-
tures: anatomic guidelines for proper
placement of internal fixation. J Shoulder
Elbow Surg 1996;5(2)[Pt 1]:113–117, with
Pronation permission.)
200 The Athlete’s Elbow
head is so comminuted that it cannot be reconstructed,
then it should be excised. If excision is required, then it is
mandatory that the lateral ligaments are repaired (the exten-
sor origin should also be repaired if it is avulsed). Metallic
spacers are used preferentially because Silastic spacers do not
provide adequate lateral reinforcement for unstable elbows.
Silicone offers minimal compressive resistance because of
its low modulus of elasticity (72,73). In our experience,
allograft replacement has not proven as reliable as metallic
spacers. We routinely remove the metallic spacers at 6
months to reduce chondrolysis of the capitellum.
A radial head fracture combined with a coronoid process
fracture is an extremely fragile pattern in terms of stability.
This combination of injuries after an elbow dislocation can
require longer protection. Open reduction and internal fixa-
tion of the radial head, coronoid process, or both should
be performed in unstable situations. Both fractures can be
approached by a posterolateral dissection and ‘‘shot-
gunning’’ open the joint. To gain access and to reduce the
coronoid fracture part of the brachialis, insertion must be
reflected (17). The brachialis inserts distal to the coronoid
process, so the reflected part of brachialis is usually small
and can be left alone or reattached distal to the area of
fixation if needed. Coronoid process fractures involving
more than 50% of its height require fixation when coupled
with elbow instability (74). The anterior buttress that the
coronoid process provides is even more important when
the regular soft tissue restraints have been avulsed by the
dislocation.
The elbow should be taken through an entire arc of mo-
tion on the operating table to assess stability after all repairs
have been completed. If the elbow is stable, motion can
begin in a hinged brace. The flexor-pronator origin should
be repaired if the elbow is still unstable after lateral repair.
If the elbow is still unstable after this, external fixation is
warranted to maintain reduction.
STANDARD APPROACHES AROUND
THE ELBOW
The posterolateral approach, or Kocher approach, is useful
for joint exploration, ligament repair, removal of loose bod-
ies, and radial head and/or neck repair or excision. The
incision should start proximal to the lateral epicondyle and
be centered over the radiocapitellar joint, continuing distally
and posteriorly over the forearm for 10 cm. Boyd’s modifi-
cation is useful if further exposure is needed. The extensor
carpi ulnaris and anconeus are reflected subperiosteally from
the ulna. The supinator is elevated anteriorly to protect the
posterior interosseous nerve. Proximal extension is accom-
plished by dissecting the brachioradialis and extensor carpi
radialis from the lateral intermuscular septum and supracon-
dylar ridge.
The medial Morrey approach can be used for open reduc-
tion and internal fixation of displaced medial epicondylar
fractures and medial ligament repair/reconstruction, or to
repair an avulsion of the flexor-pronator mass. The patient
is positioned supine and the arm is supported on a hand
table. The elbow is then flexed slightly and an 8-cm incision
is then made centered over the medial epicondyle. The ulnar
nerve should be identified and protected. A variation on this
approach involves making a straight anteromedial incision
centered over the medial epicondyle and the most medial
aspect of the flexor crease. This approach allows for explora-
tion of the brachial artery and median nerve.
The anterior approach, or modified Henry approach,
uses a bayonet-type incision, starting anterolaterally, run-
ning parallel to the elbow crease, and then extending anter-
omedially on the distal aspect. This gives excellent exposure
to the neurovascular bundle as well as the elbow joint, ante-
rior distal humerus, and proximal forearm.
Elbow arthroscopy can be used in the acute setting for
joint exploration and removal of osteochondral fragments.
Our experience using this technique for the previously men-
tioned indications is limited and review of the literature
does not provide more than anecdotal experience.
RESULTS
Mehlhoff et al. (21) examined their results in 52 elbow
dislocations and found that half had normal elbows. These
patients have full range of motion, normal strength, no pain,
and normal stability. One third of patients will have a 15-
degree loss of flexion or extension, some mild pain, and
good stability. Fair or poor results are commonly seen in
those patients with severe original injuries and these are also
associated with complications (29). Fractures of the radial
head and coronoid process negatively affect outcomes
(57,75).
There continues to be some improvement for up to a
year. If residual motion problems occur, it is usually loss of
extension. Instability of the elbow to varus or valgus stress-
ing is uncommon and is likely a result of the monoaxial joint
configuration that provides substantial geometric stability
to the joint as it heals (76–78). Twenty percent of elbow
dislocations have neurologic complications. Of the major
nerves, the ulnar nerve is the most commonly injured, fol-
lowed by the median nerve (29). The radial nerve is rarely
injured. The spectrum of injury can range from a transient
paresthesia to a permanent complete palsy. Median nerve
injuries are commonly associated with brachial artery injury.
Long-term disability frequently results if the brachial artery
is injured (62).
Approximately half of the patients followed continue to
have complaints of discomfort or other residual symptoms
(21). This is usually reported with heavy lifting using the

affected arm. Of cases that have been operatively treated,
100% have been found to have cartilage avulsions and intra-
articular loose bodies (14). These findings would explain
the posttraumatic radiographic changes seen in many el-
bows years after dislocation (65). In 60% of patients, the
injured elbow does not feel as ‘‘good’’ as the opposite unin-
jured elbow (11). A 15% loss of elbow strength can be
demonstrated with mechanical testing (57).
The most common sequela of an elbow dislocation is
loss of extension (7,30,63,65,79). On average, a 30-degree
flexion contracture is seen at 10 weeks. A 10-degree flexion
contracture is typical even after 2 years without any further
improvement (16,65). Josefsson has investigated the loss
of motion and correlated it with lateral and posterolateral
dislocations and that loss of motion was worse in adults
than in children (16,65). Gross instability is not usually
seen after elbow dislocation; however, some authors have
reported mild laxity in 20% of adults and 30% of adoles-
cents or younger patients (16,21). Linscheid and Wheeler
(29) have reported 1% to 2% occurrence of recurrent insta-
bility resulting from simple elbow dislocations. Despite the
usually positive prognosis, some patients have discomfort
or weakness during forced valgus stress activities. These ac-
tivities can include hammering, raking, sweeping, throwing,
and racket sports.
COMPLICATIONS
Compartment Syndrome
If a vascular injury has occurred, upon reperfusion, com-
partment syndrome can occur. If ischemia time has been
more than 4 hours, prophylactic forearm fasciotomies
should be performed. Even if a vascular injury has not oc-
curred, intramuscular bleeding and edema of the forearm
compartments (usually the flexor compartment) can result
in compartment syndrome. The usual signs of pain with
passive finger and wrist extension that is out of proportion
to the injury, or persistent pain not relieved by the usual
dose of narcotics. Measurement of the forearm (and hand
if suspected) compartments should be performed immedi-
ately. Volar decompression should be carried out immedi-
ately if pressures are elevated. Patients taking anticoagulants
or sustaining vascular compromise are at much higher risk
for this complication. Treatment is emergent decompressive
fasciotomy.
Postreduction management entails placing the elbow in
a well-padded splint at 90 degrees of flexion. Access to the
hand and wrist is important to monitor the patient’s neuro-
vascular status. Forearm compartment pressures should be
measured immediately at any sign of compartment syn-
drome. If arterial flow is in question, ultrasound or angiog-
raphy can be used to check this. The dressing should be
13. Elbow Dislocation 201
released anteriorly and inspection of the antecubital space
and forearm compartments should be done if compartment
syndrome or vascular compromise is suspected. Arterial in-
spection and repair and/or forearm fasciotomies should be
performed if findings warrant.
Neurovascular
Arterial injury and median nerve symptoms frequently go
hand in hand because of the proximity of artery and nerve as
they run between the brachialis and pronator teres. Stretch
injuries of the nerve must be differentiated from compres-
sive injuries (fracture, entrapment within the joint, or com-
partment syndrome). Intraarticular entrapment of the me-
dian nerve is more common in children and should be
suspected if (a) paresthesias occur after reduction, (b) widen-
ing of the medial joint space occurs, or (c) an ‘‘incomplete
feel’’ at reduction is noticed (77). A Matev sign is a radio-
graphic finding that is found late (53). The epicondylar
flare is notched by tension of the nerve over the bone.
Valgus stretching is believed to be responsible for ulnar
nerve injuries (40,62). Persistent neurologic symptoms can
result from compression within the cubital tunnel by various
causes. Ulnar nerve transposition should be considered if
symptoms do not resolve.
Vascular spasm, intimal tears, thrombosis, or rupture of
the brachial artery can occur at the time of elbow dislocation
and reduction (29,37,41). The collateral circulation can also
be disrupted, putting the forearm at risk for ischemia and
inadequate soft tissue perfusion. Suspicion of vascular injury
necessitates prompt investigation with an arteriogram and
repair of the arterial disruption. Closed dislocations of the
elbow infrequently result in brachial artery disruption. The
pulse can be diminished at the initial presentation but usu-
ally returns after reduction of the elbow joint. However,
open dislocations and fractures about the elbow are more
likely to result in brachial artery injury. An anteromedial
approach, or a ‘‘lazy S’’ approach, can be used to explore
the artery and perform the repair if needed with end-to-
end anastomosis or with an interpositional vein graft. If
ischemia time exceeds 4 hours, forearm fasciotomies are
advised to decrease the chance of compartment syndrome.
The median nerve can slip around the medial condyle
and stretch across the back of the trochlea during disloca-
tion. During reduction, the nerve can become entrapped
in the trochlear sulcus and compressed within the joint (Fig.
13.11). Most neurapraxias of the ulnar or median nerves
will recover within 3 months. The ulnar nerve is most com-
monly injured secondary to valgus stretching. The posterior
interosseous nerve branch of the radial nerve can be injured
in type 1 Monteggia fractures because of the anterior radial
head dislocation. Radial nerve injury after a simple posterior
elbow dislocation is exceedingly rare.
Hallett (55) has described three mechanisms whereby
202 The Athlete’s Elbow

Humerus

Median nerve
Type 1
Medial
epicondyle
Medial aspect of
medial condyle

Ulna

Bony tunnel

Ulnar head of
pronator teres
Type 2
Radius

FIGURE 13.11. During reduction, the nerve can become en-

trapped in the trochlear sulcus and compressed within the joint.
(From Pritchard et al. Clin Orthop, with permission.)

the median nerve can become entrapped in the elbow joint

(Fig. 13.12). After a valgus dislocation, the nerve can be-
come entrapped within the joint in the first type. The mech-
anism is avulsion of the medial epicondyle tearing of the Type 3
flexor mass, along with tearing of the ulnar collateral liga-
ments. This allows the nerve to slip behind the humerus
during dislocation. When the elbow is reduced, the nerve
becomes entrapped within the joint. With the second type
of entrapment, the nerve is lodged in the healing medial
epicondyle fracture. In the third type, the median nerve is
FIGURE 13.12. Median nerve entrapment within the joint as de-
looped in the joint anteriorly. These types of injury can be scribed by Hallett. (From Hallett J. Entrapment of the median
difficult to diagnose. Hallett described his patients as having nerve after dislocation of the elbow. J Bone Joint Surg 1981;63B:
no pain. However, other authors believe that pain is present 408–412, with permission.)
with this lesion and that the surgeon must be suspicious of
this type of entrapment (80).
An advancing Tinel sign should be seen in recovering
nerve injuries. As in other nerve injuries, regeneration occurs epicondyle or a fragment from the articular surface (4).
at nearly 1 mm/day. Electromyographic and nerve conduc- Fragments from the articular surface are much larger than
tion velocity studies are not useful within the first 4 weeks x-rays would suggest because of the radiolucent chondral
of injury. However, they can be obtained at 4 weeks postin- layer.
jury to establish a baseline study. At 3 to 4 months, if no Small fragments should be removed or excised, whereas
clinical or electrographical evidence of reinnervation is pres- larger fragments should be fixed with miniscrews or dissolv-
ent, then nerve exploration should be considered as the next able screws. Minimally displaced fractures of the radial head
step. or neck should be left alone during the early healing period
(1,81,82). Open reduction and internal fixation are required
for greater displacements. Approximately 5% to 10% of all
Articular Injuries and Associated
elbow dislocations have an associated radial head fracture,
Fractures
and unfortunately the outcome in these injuries is signifi-
If intraarticular flecks of bone are seen on postreduction x- cantly worse than that of radial head or neck fractures with-
rays, these usually are an avulsed fragment from the medial out a concomitant dislocation (1,54,83,84). Elbow dislo-

cations with radial head fractures are associated with
heterotopic ossification formation (54). Fracture disloca-
tions should be fixed within 48 hours of the injury to reduce
the chances of heterotopic ossification. If the radial head is
severely comminuted beyond repair, then excision is war-
ranted. We replace this with a titanium implant for 6
months to counter the potential for valgus instability and
attenuated healing of the medial collateral ligament. The
prosthesis also provides longitudinal stability to the radius
in those patients with interosseous membrane and distal
radioulnar joint disruption.
Positive outcomes are less likely in elbow dislocations
associated with fractures of the coronoid process, olecranon,
or radial head. Ten percent of elbow dislocations have asso-
ciated radial head fractures (7). The results are substantially
less favorable than that of simple radial head fractures (1,
54,71,83,84).
The combined injury of a radial head fracture and elbow
dislocation means that fixation of the fracture may be neces-
sary to maintain elbow stability and axial forearm stability.
For severely comminuted fractures, a titanium prosthesis
provides axial support to the radius and valgus support to
the elbow joint after radial head excision. If the interosseous
membrane is disrupted, proximal migration of the radius
will happen unless axial support is restored, by radial head
open reduction internal fixation (ORIF) or replacement by
a prosthesis.
Coronoid process fractures are seen in approximately
10% to 15% of elbow dislocations (85,86). The coronoid
provides an anterior buttress of the greater sigmoid notch
of the olecranon (see case example in Fig. 13.13). It also
serves as an attachment for the anterior bundle of the medial
collateral ligament and the middle section of the anterior
capsule (85). Regan and Morrey (85) have classified coro-
noid fractures (Fig. 13.14) into type I (avulsion of the tip),
type II (fracture involving 50% or less of the coronoid), and
type III (fracture involving more than 50% of the coronoid).
They have found problems with instability and pain in
patients with displaced type III coronoid fractures (85). Pre-
viously, it has been advocated to treat these injuries with
prolonged immobilization, rather than risk heterotopic ossi-
fication by dissecting into the brachialis. We have found
that these patients (those with type III fractures), whether
displaced or not, do better with immediate ORIF or recon-
struction of the coronoid process. In these patients we are
then able to start elbow motion at 5 to 10 days and have
not had problems with severe contracture or heterotopic
ossification. Obviously, the displaced coronoid fracture that
blocks elbow motion is a clear indication for operative re-
duction and fixation or excision of the fracture fragment.
For the globally unstable elbow or the elbow that has
had multiple fractures fixed, a hinged external fixator can
be placed to maintain elbow stability and yet provide early
motion.
13. Elbow Dislocation 203
Instability
Posterolateral rotatory instability occurs when the lateral
elbow ligaments are deficient. This results in the ulnohum-
eral joint pivoting and then opening laterally with supina-
tion (68). Posterior translation of the radial head and widen-
ing of the ulnohumeral joint space can be seen on lateral
x-ray views. Insufficiency of the lateral collateral ligament
and the secondary lateral supports are ascribed to this insta-
bility model (87). Posterolateral rotatory instability happens
mainly in elbow supination, because rotatory instability re-
duces with forearm pronation. The ulna can sag on the
humerus in the absence of competent lateral stabilizers,
causing inadequate lateral joint support. If this type of insta-
bility is suspected from x-ray views, then patients should
not supinate past neutral for 4 to 6 weeks. This restriction
gives the lateral soft tissue restraints time to heal. We com-
monly employ a hinged elbow brace or cast brace that keeps
the wrist pronated. (See Chapter 12 for further discussion
on this topic.)
After a simple dislocation, recurrent instability of the
elbow is uncommon, but when it occurs, it is usually in
young patients (65,88). Malkawi (89) has reviewed the liter-
ature on this topic and found that in all patients with recur-
rent dislocations, the original dislocation happened before
age 15 and most were males. The anterior oblique bundle
of the medial collateral ligament is the principal stabilizer
to valgus stress, and despite rupture, the elbow remains sta-
ble as long as the flexor-pronator muscles are undamaged.
The elbow can become grossly unstable if the muscles are
also torn (13).
O’Driscoll et al. (90) have described the pathomechanics
of recurrent subluxation. To test for this, the examiner
should extend the elbow with valgus stress and supination;
during this maneuver, the radial head rotates below the capi-
tellum and the ulna externally swivels on the trochlea. As
the elbow is flexed and pronated, a ‘‘clunk’’ is felt when the
elbow reduces. This results from an inadequate lateral ulnar
collateral ligament. The current treatment for recurrent
elbow dislocation or subluxation involves various tech-
niques of reconstructing the lateral ulnar collateral ligament
(6,8).
Late Contracture
Improvement in range of motion can be seen for up to 1
year. Thus, bracing and physical therapy are probably useful
for 12 months postinjury. Loss of extension is the most
common finding. If the limitation is 30 degrees or more,
early intervention is desired. Contracture release with capsu-
lolysis can frequently improve motion. This procedure
should be done by surgeons comfortable with operating
about the elbow.
 204 The Athlete’s Elbow
A D
B, C
Most patients lose the terminal 10 degrees to 15 degrees
of elbow extension. Stiffness is more common than instabil-
ity after dislocation. Secondary fibrosis and thickening of
the anterior joint capsule is usually responsible for the limit-
ing functional arc of motion. The key to an acceptable range
of motion is early active motion, preferably begun within
5 to 10 days. If range of motion has reached a plateau by
6 weeks, then dynamic elbow splints should be initiated.
When elbow contractures are more than 30 degrees at 6
months, we consider performing an elbow release (91).
Heterotopic Ossification
The lateral and medial collateral ligaments commonly have
evidence of ossification after elbow dislocation. Fortunately,
this rarely results in any appreciable impairment to the pa-
tient. Heterotopic bone can also form in the anterior cap-
sule. However, the most pathologic heterotopic bone forms
in the brachialis muscle, compromising extension and flex-
FIGURE 13.13. Anteroposterior and
lateral elbow views (A, B) of patient
with a history of elbow dislocation,
radial head excision, and ligament
repair with continued pain. Lateral
views (C, D) taken in flexion and ex-
tension reproducing patients pain;
notice loss of coronoid and presence
of subluxation. (Figure continues.)
ion of the elbow (54,92). Excision of the ossified mass
should be postponed until the bone has matured. This can
be determined by bone scan. Normally, maturation takes
about 6 to 12 months to complete (52). Excision of the
heterotopic bone with the addition of an elbow release can
result in an increased elbow arc of motion.
Seventy-five percent of cases have been reported to show
some calcification after elbow dislocation (65). Approxi-
mately 5% of cases have ossification of soft tissue that actu-
ally limits motion. Ectopic ossification can be seen on x-
ray films at 4 to 6 weeks and is usually in the brachialis
muscle if it is limiting motion. (See Fig. 13.15 for common
locations of heterotopic ossification.) Heterotopic ossifica-
tion is correlated with delayed surgical intervention, aggres-
sive passive joint manipulation in the healing phase, and
closed head injury. In patients, we commonly prescribe in-
domethacin (Indocin) for 6 weeks. In high-risk patients who
cannot tolerate nonsteroidal antiinflammatory drugs, we
consider low-dose irradiation.
 13. Elbow Dislocation 205

E F

FIGURE 13.13. Continued. Anteroposter-

ior, lateral, and oblique views (E–G) showing
reconstruction of coronoid with allograft
and titanium radial head replacement. H:
Lateral view of contralateral elbow for com-
G,H parison.

FIGURE 13.14. Classification of coronoid fractures. (From Regan W,

Morrey BF. Fractures of the coronoid process of the ulna. J Bone Joint Surg
1989;71A:1348–1354, with permission.)
206 The Athlete’s Elbow
Recurrent Dislocation
In the acute setting, recurrent elbow dislocation usually fol-
lows the ‘‘terrible triad,’’ consisting of elbow dislocation,
radial head fracture, and coronoid process fracture. Fixation
of the fractures should be done first. If the elbow is still
unstable, repairing the medial and lateral ligaments should
be considered. Hinged external fixation may allow motion
without loss of congruent reduction. Pinning of any type
across the joint is emphatically discouraged. This method,
even on a temporary basis, can result in (a) a stiff elbow, (b)
chondrolysis, (c) heterotopic ossification, and (d) hardware
breakage necessitating even more traumatizing surgery to
remove the metallic parts. When hinged fixation is used, it
commonly in employed for about 8 weeks. The joint should
be reduced before fixator application. Next, suture anchors
are placed through the lateral capsule. These are then tied
isometrically after the hinge is in place. Medial repair can
be considered if the flexor-pronator mass has been torn from
the medial epicondyle.
Chronic Dislocation or Unreduced
Dislocations
General anesthesia is usually necessary in attempting to re-
duce elbow dislocations more than 2 weeks out from injury.
If closed reduction cannot be achieved, open reduction
through a long extensile posterolateral approach should be
considered. Release of the concomitant contracture should
be performed at the time of open reduction. The further out
from initial injury, the more musculotendinous retraction,
scarring, and joint degeneration will be present. The patient
with an abnormal joint and intractable symptoms may be
considered for arthrodesis or arthroplasty as a last resort.
The triceps tendon functionally shortens the longer the
joint is dislocated. This makes flexion after reduction and
maintenance of reduction difficult in these elbows. A com-
FIGURE 13.15. Common sites for hetero-
topic ossification formation. (From Has-
tings H II, Graham TJ. The classification and
treatment of heterotopic ossification
about the elbow and forearm. Hand Clin
1994;10:417–438, with permission.)
plete open release and reduction of the elbow is performed.
We routinely perform an anterior ulnar nerve transposition,
because in our experience, these tissues have contracted
along with everything else, and once the elbow is relocated,
undue tension is placed on the nerve with subsequent ulnar
nerve symptoms. The organized hematoma and scar must
be carefully removed from the joint so as not to damage
the fragile articular surfaces. Joint capsule must be released
both anteriorly and posteriorly. A V-Y plasty of the triceps
is usually necessary if the elbow has been out more than 3
months. Ligament repair or reconstruction is performed as
needed. If reduction cannot be maintained, a dynamic exter-
nal fixator is employed. This type of surgery should only
be done in a mentally alert and compliant patient. Current
thinking advocates open reduction in children regardless of
the length of dislocation. However, demented and otherwise
noncompliant patients should not have their chronic dislo-
cations reduced for reduction’s sake alone. These procedures
are fraught with complications, and the patient must be
able to actively participate in treatment.
REFERENCES
1. Adler B, Shaftan GW. Radial head fractures: is excision necessary?
J Trauma 1964;4:115.
2. Eppright RH, Wilkins KE. Fractures and dislocations of the
elbow. In: Rockwood CA, Green DP, eds. Fractures, vol 1. Phila-
delphia: JB Lippincott Co, 1975.
3. Dryer RF, Buckwalter JA, Sprague BL. Treatment of chronic
elbow instability. Clin Orthop 1980;148:254–255.
4. Grant IR, Miller JH. Osteochondral fracture of the trochlea asso-
ciated with fracture—dislocation of the elbow. Injury 1975;6(3):
257–260.
5. Sojbjerg JO, Helmig P, Kjaersgaard-Anderson P. Dislocation of
the elbow: an experimental study of the ligamentous injuries.
Orthopedics 1989;12:461–463.
6. Hassman GC, Brunn F, Neer CS. Recurrent dislocation of the
elbow. J Bone Joint Surg 1975;57A:1080–1084.