(Also known as Elbow Dislocation, Posterior Dislocation of the Elbow)
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
Physiotherapy for a dislocated elbow
Physiotherapy treatment is essential for all patients with a dislocated elbow as inadequate rehabilitation can result in a poor outcome with a high likelihood of re-injury. Physiotherapy can hasten the healing process, ensure an optimal outcome and reduce the likelihood of recurrence. Treatment may comprise:
- soft tissue massage
- electrotherapy (e.g. ultrasound)
- anti-inflammatory advice
- joint mobilization
- elbow taping
- elbow bracing
- ice or heat treatment
- exercises to improve flexibility and strength
- activity modification advice
- a gradual return to activity program
Other intervention for a dislocated elbow
Despite appropriate physiotherapy management, a small percentage of patients with a dislocated elbow do not improve adequately. When this occurs the treating physiotherapist or doctor can advise on the best course of management. This may involve further investigations such as an X-ray, CT scan, bone scan or MRI, pharmaceutical intervention, corticosteroid injection or a review by a specialist who can advise on any procedures that may be appropriate to improve the condition. Surgical intervention may be indicated to repair the torn connective tissue or to correct other abnormalities associated with the dislocated elbow (such as fractures).
Exercises for a dislocated elbow
The following exercises are commonly prescribed to patients who are allowed to commence mobilization (as directed from their orthopaedic specialist) following a dislocated elbow. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed 3 times daily and only provided they do not cause or increase symptoms.
Elbow Bend to Straighten
Bend and straighten your elbow as far as possible pain free (figure 2). Aim for no more than a mild to moderate stretch. Repeat 10 times provided there is no increase in symptoms.
Begin this exercise with your elbow at your side and bent to 90 degrees (figure 3). Slowly rotate your palm up and down as far as possible pain free. Aim for no more than a mild to moderate stretch. Repeat 10 times provided there is no increase in symptoms.
Tennis Ball Squeeze
Begin this exercise holding a tennis ball (figure 4). Squeeze the tennis ball as hard as possible and comfortable without pain. Hold for 5 seconds and repeat 10 times.
Physiotherapy products for a dislocated elbow
Some of the most commonly recommended products by physiotherapists to hasten healing and speed recovery in patients with a dislocated elbow include:
To purchase physiotherapy products for a dislocated elbow click on one of the above links or visit the PhysioAdvisor Shop .
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