Bone & Joint Expert Care
When the joint surfaces of an elbow are forced apart, the elbow is dislocated. The elbow is the second most commonly dislocated joint in adults (after shoulder dislocation). Elbow dislocations can be complete or partial. A partial dislocation is referred to as a subluxation. The amount of force needed to cause an elbow dislocation is enough to cause a bone fracture at the same time. These two injuries (dislocation-fracture) often occur together.
This guide will help you understand
• how the problem develops
• how doctors diagnose the condition
• what treatment options are available
What part of the elbow is affected?
The bones of the elbow are the humerus (the upper arm bone), the ulna (the larger bone of the forearm, on the opposite side of the thumb), and the radius (the smaller bone of the forearm on the same side as the thumb).
The elbow itself is essentially a hinge joint, meaning it bends and straightens like a hinge. But there is a second joint where the end of the radius (the radial head) meets the humerus. This joint is complicated because the radius has to rotate so that you can turn your hand palm up and palm down. At the same time, it has to slide against the end of the humerus as the elbow bends and straightens. The joint is even more complex because the radius has to slide against the ulna as it rotates the wrist as well. As a result, the end of the radius at the elbow is shaped like a smooth knob with a cup at the end to fit on the end of the humerus. The edges are also smooth where it glides against the ulna.
Articular cartilage is the material that covers the ends of the bones of any joint. Articular cartilage can be up to one-quarter of an inch thick in the large, weight-bearing joints. It is a bit thinner in joints such as the elbow, which don't support weight. Articular cartilage is white, shiny, and has a rubbery consistency. It is slippery, which allows the joint surfaces to slide against one another without causing any damage. In the elbow, articular cartilage covers the end of the humerus, the end of the radius, and the end of the ulna.
There are several important ligaments in the elbow. Ligaments are soft tissue structures that connect bones to bones. The ligaments around a joint usually combine together to form a joint capsule. A joint capsule is a watertight sac that surrounds a joint and contains lubricating fluid called synovial fluid.
In the elbow, two of the most important ligaments are themedial collateral ligament and the lateral collateral ligament. The medial collateral is on the inside edge of the elbow, and the lateral collateral is on the outside edge. Together these two ligaments connect the humerus to the ulna and keep it tightly in place as it slides through the groove at the end of the humerus. These ligaments are the main source of stability for the elbow. They can be torn when there is an injury to or dislocation of the elbow. If they do not heal correctly the elbow can be too loose, or unstable.
There is also an important ligament called the annular ligament that wraps around the radial head and holds it tight against the ulna. The word annular means ring-shaped. The annular ligament forms a ring around the radial head as it holds it in place. This ligament can be torn when the entire elbow or just the radial head is dislocated.
What can cause this condition?
Elbow dislocation is often the result of trauma. The most common trauma resulting in an elbow dislocation is a fall onto an outstretched hand and arm. When the hand hits the ground, the force is transmitted through the forearm to the elbow. This force pushes the elbow out of its socket.
This can also result in a fracture/dislocation. About half of all elbow dislocations in teens and young adults occur as a result of a sports activity. The most common elbow dislocations are associated with sports such as gymnastics, cycling, rollerblading, or skateboarding.
Dislocation can also occur from a sideswipe injury. This type of injury occurs when the driver of an automobile has the elbow out the open window during a car accident. The force of the impact causes a severe fracture-dislocation of the elbow.
What does this condition feel like?
If the elbow is fully dislocated, it will look out of joint. There may be dimples or indentations of the skin over the dislocation where the bones have shifted position. Pain can be intense until the arm is relocated. The pain is often relieved immediately after the joint is put back in place. There may be some residual tenderness around the joint.
If ligaments or other soft tissues are torn, there can be swelling and bruising around the elbow. Bruising is not immediately obvious but appears several days after the injury. Injury to any of the three nerves that cross the elbow (median, ulnar, radial nerves) can cause neurologic symptoms such as numbness, tingling, and/or weakness of the forearm, wrist, and hand. If a bone fracture is also involved the fracture can cut or damage a nerve causing temporary or permanent paralysis.
Pain and an inability to straighten the elbow or pain when turning the hand the palm up (supination) is typical. There is often tenderness along the lateral aspect of the elbow (side of the elbow away from the body).
How do doctors diagnose elbow dislocation?
The history and physical examination are probably the most important tools the physician uses to guide his or her diagnosis. Moving the elbow passively is painful, especially extension and supination. The doctor will check for any signs of injury to the nerves or blood vessels.
X-ray is the best way to look for dislocation or fracture-dislocation.
After the joint is relocated, other imaging studies may be ordered to look for damage to the joint cartilage, bone, ligaments, and other soft tissues. If bone detail is difficult to identify on an X-ray, a computed tomography (CT) scan may be done. If it is important to evaluate the ligaments, a magnetic resonance image (MRI) can be helpful.
What treatment options are available?
It is possible for the elbow to relocate by itself. This is more likely when there is a subluxation, rather than a complete dislocation. Sometimes the elbow can be reduced or put back in place by a trained medical person applying a quick motion to the forearm. There are several different methods used for manual (closed) reduction. Closed reduction refers to the fact that the elbow can be put back in joint without surgery. An open incision is not needed.
Manual reduction can be done in an emergency on site (e.g., at an athletic event or car accident) by a trained medical person but usually the procedure is done in a clinic or hospital setting. You would be given medications first to help with the pain.
If there is too much swelling, it may be necessary to delay surgery for a few days up to a week. The elbow will be reduced right away and the arm immobilized while waiting for the swelling to subside.
If there has been damage to the bones and/or ligaments, surgery may be needed to restore alignment and function. The type of surgery depends on the extent of the damage. Wires, pins, or even an external fixation device may be needed to hold everything together until healing occurs.
What should I expect after treatment?
Simple elbow dislocations heal well with few (if any) problems. You may notice a slight loss of elbow motion, especially when trying to straighten the arm. This should not affect your overall motion and function. X-rays may be taken while the elbow heals. This will show if the bones of the elbow joint are healing in a reduced position with good alignment.
The arm may be immobilized for 10 to 14 days to allow the ligament to heal. Gentle range of motion may be allowed during that time but you should rely on your physician to advise you. Type of activities and movements allowed are determined according to the type of injury that's present.
After immobilization, physical therapy may begin. The goal is to restore normal motion, joint proprioception (sense of position), and motor control. The program will progress to include strengthening.
Rehabilitation for the athlete includes sport-specific training is part of the rehab program. Your physical therapist will guide you through this process. Most athletes can resume sports participation three to six weeks after an elbow dislocation. The timing of return to sports depends on the type of sport (e.g., throwing sports may require a longer rehab). Dislocation of the dominant hand may require longer rehab before full motion and strength are restored.
Some athletes continue to wear a protective splint and/or use taping to stabilize the joint during the transition back into action. This can help protect the joint during motion and activity during the final phase of healing.
It's best to avoid any further traction on the elbow until healing has occurred. Pulling a heavy door open, carrying a heavy purse, or lifting a heavy backpack are a few examples of activities and movements that put a traction force through the elbow. These kinds of movements should be avoided until healing occurs.
Post-operative immobilization is often required, especially for complex injuries. This could be a cast, dynamic splint, or postoperative range-of-motion (ROM) brace. The adjustable ROM brace is used to improve elbow motion gradually while allowing soft tissue healing. It helps minimize scar tissue formation and may contribute to fewer complications (such as arthritis) later on.
After immobilization, physical therapy may begin. The goals are the same as for conservative (nonoperative) care: restore normal motion, joint proprioception (sense of position), and motor control. The program will progress to include strengthening. Rely on your doctor and therapist to guide you through the healing process.
As in conservative care, some athletes continue to wear a protective splint and/or use taping to stabilize the joint during the transition back into action. This can help protect the joint during motion and activity during the final phase of healing.
It's best to avoid any further traction on the elbow until healing has occurred. Pulling a heavy door open, carrying a heavy purse, or lifting a heavy backpack are a few examples of activities and movements that put a traction force through the elbow. These kinds of movements should be avoided until healing occurs. Your doctor and/or therapist will advise you as you progress through the healing process.
Scar tissue can cause a stiff elbow. Recurrent dislocation is also possible. If either of these problems develops, additional reconstructive surgery may be needed. For some patients, arthritis is a long-term result of elbow injury. This is more likely if there is a history of recurrent elbow dislocations.
What is a dislocated elbow?
A dislocated elbow is a condition characterized by damage and tearing of the connective tissue surrounding the elbow joint with subsequent displacement of the bones forming the joint so they are no longer situated next to each other. A dislocated elbow is one of the most serious elbow injuries.
The forearm comprises of 2 long bones, known as the radius and the ulna, which are situated beside each other (figure 1). These bones join with each other and the humerus to form the elbow joint (figure 1). The elbow joint comprises of strong connective tissue surrounding the joint known as the joint capsule and several ligaments providing additional stability. Numerous muscles around the elbow provide additional support.
During certain movements of the elbow, stretching forces are applied to the elbow joint capsule. When these forces are excessive and beyond what the elbow can withstand, tearing of the connective tissue may occur. This may allow the bones forming the elbow joint to move out of their normal position if the forces involved are too great and beyond what the connective tissue and supporting muscles can withstand. When this occurs, the condition is known as a dislocated elbow.
Due to the large forces required to dislocate the elbow, this condition usually occurs in combination with other injuries of the wrist, elbow or forearm such as fractures, ligament or muscle tears, cartilage or nerve damage. Occasionally blood vessels may also be compressed with very severe consequences unless quickly rectified.
Causes of a dislocated elbow
A dislocated elbow typically occurs traumatically due to forces pushing the elbow bones apart. This may occur following a direct impact (e.g. during contact sports), motor vehicle accident or more commonly, due to a fall onto the outstretched hand or arm (especially from a height and onto a hard surface). Elbow dislocations are occasionally seen in contact sports such as rugby and football where heavy collisions are common.
Signs and symptoms of a dislocated elbow
Patients with a dislocated elbow usually experience sudden severe pain at the time of injury. The pain is usually so intense that the patient cannot continue activity and may cradle the arm against the body in attempt to protect the elbow. Pain is usually felt in the elbow region, however can occasionally radiate into the arm, forearm, hand or fingers.
Patients with this condition will often experience a sensation of the elbow 'moving out' at the time of injury. Swelling and a visible deformity of the elbow may be detected when compared to the other side along with bruising which may become more visible over time. Pain will usually increase on firmly touching the affected region of the elbow joint. Loss of elbow movement is usually experienced which may worsen over the coming days as swelling increases. Occasionally, patients may experience pins and needles or numbness in the elbow, forearm, hand or fingers. An absence of pulses in the forearm, wrist or hand may be experienced in some cases involving damage to blood vessels and is considered an emergency, requiring the patient to seek medical assistance immediately.
Once a dislocated elbow has been 'relocated' (i.e. the bones put back into their normal position by a sports medicine professional or orthopaedic specialist), patients may experience a feeling of weakness and stiffness in the elbow and an ache that may increase to a sharper pain with certain movements. Most of these symptoms generally resolve over time with appropriate rehabilitation. However due to the seriousness of this condition, patients with a dislocated elbow may experience long term problems such as elbow stiffness, weakness and a feeling of impending dislocation when the elbow is placed in certain positions.
Diagnosis of a dislocated elbow
A thorough subjective and objective examination from a physiotherapist may be sufficient to diagnose a dislocated elbow. All elbow dislocations should be X-rayed to confirm diagnosis, assess the severity and rule out other injuries (particularly fractures). Further investigations such as an MRI, CT scan or bone scan may be required to assist with diagnosis and assess the severity of the injury. Post reduction X-rays should also be performed.
Treatment for a dislocated elbow
Patients with a dislocated elbow require immediate medical attention. In some cases, damage to local blood vessels may occur with very severe consequences if not rectified immediately. Assessment of pulses is vital to determine if this may be the case. If pulses are absent, immediate relocation of the elbow is required to reduce compression of the local blood vessels and restore blood flow to the forearm and hand. If pulses are still absent following relocation, immediate surgical intervention is indicated.
Patients who do not have vascular compromise should usually have elbow X-rays to determine if there are any fractures associated with the dislocation prior to attempting relocation. Following X-ray an experienced sports medicine professional or orthopaedic specialist can assist with safely 'relocating' the elbow bones into their original position. This should not be attempted alone, as serious long term damage may occur to other structures around the elbow such as nerves, blood vessels, bones, ligaments and cartilage if the elbow relocation is performed incorrectly.
A review with an orthopaedic specialist is essential to ensure optimal management, particularly in the case of a dislocated elbow with associated fractures. Treatment may involve anatomical reduction of any displaced fractures (i.e. re-alignment of the fracture by careful manipulation under anesthetic), surgical internal or external fixation to stabilize the elbow or fracture (e.g. using plates and screws), plaster cast immobilization, the use of a brace and/or sling for a number of weeks. The orthopaedic specialist will determine the most suitable treatment based on a number of factors including the severity of injury and other associated injuries (e.g. fractures / blood vessel damage).
Following relocation of the elbow and appropriate orthopaedic specialist treatment of any associated injuries (e.g. fractures / blood vessel damage), all patients should undergo an intensive physiotherapy rehabilitation program. The success rate of treatment is largely dictated by patient compliance. Treatment for a dislocated elbow usually entails early mobilization exercises as guided by the orthopaedic specialist and physiotherapist to prevent stiffness and weakness from developing.
Physiotherapy treatment and appropriate rehabilitation for a dislocated elbow can begin once the orthopaedic specialist has indicated that it is safe to do so. One of the most important components of rehabilitation is that the patient rests sufficiently from any activity that increases their pain (a sling or elbow brace may be required). Activities which place large amounts of stress through the elbow should also be avoided particularly lifting, lying on the elbow, pushing or pulling activities. Rest from aggravating activities allows the healing process to take place in the absence of further damage. Once the patient can perform these activities pain free, a gradual return to these activities is indicated provided there is no increase in symptoms. This should take place over a period of weeks to months (depending on the severity of injury) with direction from the treating physiotherapist and orthopaedic specialist.
Ignoring symptoms or adopting a 'no pain, no gain' attitude is likely to cause further damage and may slow healing or prevent healing altogether.
Patients with a dislocated elbow usually benefit from following the R.I.C.E. Regime. The R.I.C.E regime is beneficial in the initial phase of the injury (first 72 hours) or when inflammatory signs are present (i.e. morning pain or pain with rest). This should involve resting from aggravating activities, regular icing, the use of a compression bandage and keeping the elbow elevated. Heat, alcohol and massage should also be avoided in the initial 72 hour period following injury or when inflammatory signs are present. Anti-inflammatory medication may also benefit those with a dislocated elbow by reducing the pain and swelling associated with inflammation and reducing other complications (such as abnormal bone formation).
Patients with a dislocated elbow should perform pain-free flexibility, and strengthening exercises as part of their rehabilitation to ensure an optimal outcome. This is particularly important, as soft tissue flexibility and strength are quickly lost with inactivity. The treating physiotherapist can advise which exercises are most appropriate for the patient and when they should be commenced.
Manual "Hands-on" Therapy from the physiotherapist such as massage, mobilization, dry needling, stretches and electrotherapy can also assist with improving elbow range of movement and function following a dislocated elbow. This can generally commence once the orthopaedic specialist or physiotherapist has indicated it is safe to do so.
In the final stages of rehabilitation for a dislocated elbow, a gradual return to activity or sport can occur as guided by the treating physiotherapist provided there is no increase in symptoms.
It may be advised upon returning to some sports, particularly contact sports such as football and rugby, that the elbow is either taped or braced for additional support or protection. The treating physiotherapist can advise if this is recommended.
Prognosis of a dislocated elbow
Many patients with a dislocated elbow heal well with appropriate physiotherapy and return to normal function. This may take weeks to months to achieve an optimal outcome. However, due to the severity of injury and widespread connective tissue damage associated with this condition, patients may experience long term effects. Some of the most common long term effects of a dislocated elbow include reduced elbow range of movement (especially extension) and an increased likelihood of future dislocation or elbow sprain. In cases of recurrent elbow dislocation, surgical intervention may be indicated to increase the elbow's stability. This is usually followed by an extensive rehabilitation program lasting many months.
Patients with a dislocated elbow who also have damage to other structures such as cartilage, bone, muscle, nerves or blood vessels are likely to have a significantly extended rehabilitation period to gain optimum function.
Contributing factors to the development of a dislocated elbow
There are several factors which can predispose patients to dislocating their elbow. These need to be assessed and where possible, corrected with direction from a physiotherapist. Some of these factors may include:
• history of a previously dislocated elbow or elbow instability
• inadequate rehabilitation following an elbow dislocation
• participation in sports or activities placing the elbow at risk of dislocation
• elbow weakness
• elbow joint hyper mobility
• inappropriate training technique