Broken and Dislocated Elbows / Complex Elbow Injuries

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Physical Therapy Videos - Elbow

Basic Anatomy

The elbow is the complicated joint that links your arm and your forearm. The elbow joint allows you to position your hand closer to your body or move it away. This is referred to as flexion and extension. The elbow is also involved in flipping your hand palm-up and palm-down. This is referred to as pronation and supination. Because the elbow plays such a large role in moving the hand to the desired location, it’s important to preserve movement after an injury.

Skeleton model showing the elbow joint and the bones that are involved in forming the joint
Figure 1: Skeleton model showing the elbow joint and the bones that are involved in forming the joint. As shown above the elbow is made up of three bones: the humerus is your upper arm bone and your forearm has two bones in it—the ulna (pointy bone at your elbow) and the radius (the bigger bone at your wrist).

 

X-rays of a normal elbow showing the elbow joint and the bones that make up the joint
Figure 2: X-rays of a normal elbow showing the elbow joint and the bones that make up the joint.

Mechanism

Elbow fracture dislocations (one or more bones are broken and the joint is out of place) are serious injuries. They often happen after falling onto your outstretched hand. The fracture(s), or broken bones, tend to happen in the radius and ulna, which are the bones in the forearm. If the break in the radius is at the elbow joint, this injury is often referred to as the "terrible triad," because the radius bone breaks (1), the ulna bone breaks (2), and the elbow dislocates (3). People with this injury will have immediate pain, a crooked arm, and will not be able to bend or straighten their arm. They may have numbness or tingling in their hand. Rarely, some people can damage the blood supply to their arm.

Photograph of an elbow fracture dislocation, showing the amount of swelling and bruising that is seen after this injury
Figure 3: A photograph of an elbow fracture dislocation, showing the amount of swelling and bruising that is seen after this injury.

 

X-rays of elbow fracture dislocations.
Figure 4: X-rays of elbow fracture dislocations. #1 shows the break in the radius. #2 shows the break in the ulna. #3 shows the elbow joint completely out of place, or dislocated.

Initial Treatment

Elbow fracture dislocations need to be treated as soon as possible in the nearest appropriately equipped emergency room. You will be examined to make sure the nerves and arteries to your hand are working. The next test will be an x-ray to see if there are breaks in the bones. Once the diagnosis of an elbow fracture dislocation is made, you will need to have your elbow set back in place, or "reduced," usually, but not always, in the emergency room. If attempted, you will typically get medications to decrease your pain and make you sleepy. Once you are relaxed and sleepy, the doctors will gently pull on your arm and move the elbow joint and bones back in place as best they can. You then will then have your arm placed in a splint with your elbow in a bent position. Sometimes, you will get a CT scan to better visualize your elbow. Depending on your exact injury, the next step may or may not be surgery.

Surgical Care

Surgery is often needed to treat elbow fracture dislocations. If the elbow can be put back in place, then surgery will likely occur after the swelling has gone down. This may be within a few days of the injury. However, if the elbow cannot be put back in place or will not stay in the proper position, surgery will likely be sooner. In surgery, an incision or "cut" is made over the elbow, the bones are realigned, and metal plates and/or screws are used to hold the bones together until they heal. The ligaments (soft tissues that connect bone to bone) around the elbow may be repaired to keep the elbow positioned correctly. Occasionally the "head," or top/disc of the radius bone, cannot be repaired and needs to be replaced with a metal piece. This will be determined by your surgeon. Often this decision is made during surgery. After surgery, you will likely be sent home in a splint, cast, or brace. After a 7-14 days you will return for follow-up with your doctor.

X-ray of elbow fracture dislocations after surgery
Figure 5: X-ray of elbow fracture dislocations after surgery. Image A shows screws in the radius bone and a plate and screw used in the ulna bone. B shows a plate on the radius bone and suture repair of the ulna bone fracture (sutures are not visible on x-ray). C shows a metal head replacement placed in the top of the radius bone and suture repair of the ulna bone fracture. All of the x-rays show the elbows located, or properly positioned.

PostOperative Care

After some days in a cast, splint, or brace, you will have your sutures removed and be allowed to start moving your elbow. This is important to regain movement and prevent your elbow from becoming very stiff. Stiffness can be a problem after elbow fracture dislocations. Typically, your doctor will limit your activities for 6-12 weeks after the injury, perhaps placing you in a custom splint. When you start therapy, they may restrict how straight you can make your elbow. The reason for this is the elbow is less likely to dislocate again if it is kept slightly bent. Gradually over time, your doctor will let you work on full straightening of the arm. Periodic x-rays will confirm the elbow is still positioned correctly.

Long Term

Long-term issues after elbow fracture dislocation include stiffness or repeat dislocations. Stiffness is common. Patients typically are not able to get their arm all-the-way straight after a dislocation. Fortunately, you can still function well, even if you are unable to get your arm all-the-way bent or straight. Doing therapy and following your doctor’s instructions is the best way to avoid significant stiffness. Repeat dislocations are rare. This usually occurs in the days or weeks following the injury. Repeat dislocation almost never happens after the elbow has healed. Other problems after surgery can include infections, hardware irritation, problems with the bone healing, or extra bone forming. Too much bone, or extra bone, forming in the body after an injury is called heterotopic ossification. This can be mild and have no effect, or can be severe and require additional treatment. Patients with elbow dislocations may develop elbow arthritis years after the injury.

"CAT- scan" of an elbow fracture dislocation that formed heterotopic ossification (extra bone)
Figure 6: "CAT- scan" of an elbow fracture dislocation that formed heterotopic ossification (extra bone). Surgery will likely be required in this case because it made the elbow joint very stiff.

 

Physical Therapy Videos - Elbow

More Information

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Christopher Doro, MD
Edited by the OTA Patient Education Committee and Steven Papp, MD (section lead)
All x-rays and pictures taken from the personal collection of Dr Doro