The authors of these consumer health information handouts have made a considerable effort to ensure the information is accurate, up to date and easy to understand. predominantly affects patients between age 10-20 years old; Pathophysiology . Anteroposterior (AP) radiographs show the distal humerus superimposed distally over the proximal forearm, with the proximal radius and ulna usually displaced in a posterior and lateral direction. Indeed, if not free to do so, these osseous landmarks are at risk of fracture. Once diagnosed, the first step in treatment is to advise the child and the family that there will be a brief period of pain, followed almost immediately by relief and usage of the affected limb. It is usually the result of a fall onto an outstretched hand, often with a large amount of force involved. Originally it was thought that the injury occurred with the elbow extended and the forearm supinated. (A) The posteriorly dislocated elbow is supinated (movement 1) to unlock the radial head from behind the capitellum. Elbow dislocations are occasionally seen in contact sports such as rugby and football where heavy collisions are common. 72,118 In general, however, because the attachments of ligaments and muscles are stronger than the adjacent growth plate, forces exerted about most joints tend to result in epiphyseal injury rather than simple dislocation of the adjacent joint. We present the case of an 11-year-old girl with an elbow dislocationtreated by closed manual reduction. Although elbow dislocations are much less common than fractures,3 it is important to make a prompt diagnosis since in the majority of patients this will enable closed reduction and result in a rapid return of normal function and appearance of the elbow. Arterial damage to the main brachial trunk is rare.16,17 However, complete rupture, an intimal tear or simple kinking into the elbow joint can occur because of the tethering effect of the collaterals and surrounding soft tissue restraints. Less common fractures occur to the coronoid and medial condyle. Figure 13.3 Longitudinal traction on a pronated forearm is the typical mechanism for subluxation of the radial head, commonly termed ‘pulled elbow’ or ‘nursemaid’s elbow’. When this valgus force is applied to either the hyperextended or semi-flexed elbow, the medial collateral ligament is torn or the medial epicondyle and common flexor origin are avulsed. This allows the majority of uncomplicated, isolated dislocations to be reduced quickly and safely in the emergency department, provided that the procedure is undertaken by experienced staff. The typical scenario is a parent suddenly pulling their child by the arm. An elbow dislocation is a serious injury that needs medical care. The prognosis is good for uncomplicated elbow dislocations treated appropriately. Limited published recommendations for the management of these lesions in children are available. It is estimated to occur between 3% to 6% of all paediatric elbow injuries 1–4. Following the reduction, the child gets immediate relief from the elbow pain. Children should not be referred for physiotherapy after elbow dislocations, and parents need to be explicitly warned not to seek any form of therapy which includes passive stretching. The majority of elbow dislocations are managed by closed reduction. 13.2). Lateral radiographs confirm a posterior dislocation of the elbow (Fig. Exercises are the mainstay of treatment after reduction and/or surgery for elbow dislocations and/or fracture-dislocations. Given that more than 50% of elbow dislocations in children have associated fractures, the radiographs must be carefully examined for bony injuries (medial epicondyle, radial neck and coronoid). Developed by The Royal Children's Hospital Emergency department. A pulled elbow is a result of the lower arm (radius bone) becoming partially dislocated (slipping out) of its normal position at the elbow joint. To donate, visit www.rchfoundation.org.au. If my child has had a pulled elbow once, is he more likely to have it again because his ligament has stretched? The child presents with a swollen elbow and limited movement. Leave the room to allow the child time to start using the arm. A pulled elbow will not cause any long-term damage to your child. The diagnosis of a lateral condyle fracture can be challenging. Failed closed reduction in the emergency department is distressing for children and parents. elbow dislocations are the most common major joint dislocation second to the shoulder . These forces must be overcome so as to allow the coronoid process of the ulna and the radial head to pass unimpeded from posterior to anterior. A pulled elbow will be put back into place by a nurse practitioner or doctor. Figure 13.1 Typical mechanism of a child falling on an outstretched hand, which can result in various injuries to the upper limb. The medial epicondyle fracturewas missed initially … Is this dangerous? It can also happen when a child falls. 1 In the present case, an avulsed fragment of the LCL attachment caused recurrent dislocation. Approximately 65% of all fractures in children are to the upper limb, with the vast majority the result of indirect forces, following a fall on the outstretched hand (Fig. Closed reduction was unsuccessful; open reduction and internal fixation was performed with headless screws. The toddler tries to go in one direction, while the parent pulls in another. 13.3). These are the brachialis and biceps anteriorly and the triceps posteriorly. Primary ligament repair is not an appropriate indication as studies have shown that the outcome is inferior to closed treatment.21,22. (C) The forearm is flexed (4) to maintain the reduction. To unlock the radial head and coronoid process from behind the distal humerus, some authors have previously advocated initial hyperextension.20 This, however, has been shown to produce excessive force on an already stretched brachialis, which can cause rupturing of the muscle and the anterior capsule. The majority of elbow dislocations are managed by closed reduction. Log In or, Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window). However, it is now widely believed that subluxation results when the pronated, extended forearm of an infant has forcible traction applied through the longitudinal axis. The principle of reduction is to counteract the muscle forces that are maintaining the dislocation. Ultrasonography can provide inconsistent results8 and is very rarely used in our emergency department. Posterolateral dislocation of the elbow is typically the result of indirect trauma and most frequently occurs as the result of a fall on the outstretched hand. Their arm may simply hang by their side. Originally it was thought that the injury occurred with the elbow extended and the forearm supinated. The now free radial and ulnar articular surfaces are then either pushed (from pressure on the olecranon) or pulled (via longitudinal traction on the forearm), enabling relocation of the joint. The medial structures of the elbow joint are integral to joint stability, and axial force from a fall is transmitted to the medial elbow by the medial crista of the trochlear, exaggerating the natural valgus carrying angle of the elbow. However, if the elbow was partially dislocated for quite a while, then your child may need some pain medicine for a day or two. Flexion at the elbow may also be required. Divergent dislocations and translocation dislocations are even rarer and can only occur in association with disruption of the PRUJ. Complex elbow dislocation consists of both ligamentous and bony injuries. When the injury occurs: The child usually begins crying right away and refuses to use the arm because of elbow pain. Isolated elbow dislocations involving both the capitellar–radial and trochlear–ulnar joints are uncommon in children and more frequently the dislocation is associated with fractures about the elbow. The dislocated elbow is clearly visible from outside. If a pulled elbow is not able to be put back into place, or your child is still not using the injured arm, an X-ray may be ordered to check for other possible injuries such as a fracture. Some children are more likely than others to get a pulled elbow. 50 Flemington Road Parkville Victoria 3052 Australia, Site Map | Copyright | Terms and Conditions, A great children's hospital, leading the way. The injury is extremely common and, because the majority of pulled elbows are treated in emergency departments or the offices of paediatricians or GPs; the exact incidence is not known. Your child will be observed for a short while to check that they are using their arm without any problems or pain. Elbow, dislocation, children, injuries, outcome INTRODUCTION Paediatric traumatic elbow dislocation, is an uncommon injury1. Adequate analgesia and anaesthesia are always essential to permit a safe and effective reduction of the elbow. Additional indications are the treatment of associated fractures, existing open injury or the investigation of neurovascular compromise. Indeed, if not free to do so, these osseous landmarks are at risk of fracture. There may be signs of generalized joint laxity in the child and in one or both parents. In most cases, children with a pulled elbow will cry immediately after the sudden pull, and not use the injured arm at all. First, traction longitudinally down the arm and supination of the forearm aids unlocking of the proximal radius and ulna. This will help with the pain and will reduce some of the swelling. Dislocated elbow toddler / child. A typical history and examination obviate the need for further investigations. Early closed manipulation in the emergency department, without sedation, is the preferred treatment. A dislocated elbow occurs when the bones that make up the joint are forced out of alignment — typically when you land on an outstretched hand during a fall. It involves gently moving the bone and ligament back into place. It will not cause any long-term damage to your child. A shorter period of immobilization (1–2 weeks) can be considered in selected older children if there are concerns about elbow stiffness and a particular need to regain full elbow extension for occupational or sporting requirements. (C) The forearm is flexed (4) to maintain the reduction. If the child is still unable to move his/her hand normally, the doctor will repeat the reduction. Falling onto the outstretched hand in a child aged 12–14 years is a common cause of elbow dislocation. Figure 13.2 (A) AP and (B) lateral radiographs of the left elbow of a girl involved in a motor vehicle accident, demonstrating multi-trauma in a single arm: a fracture of the distal humerus and a Bado type 1 Monteggia fracture–dislocation of the forearm. If your child is not moving their arm fully by the next day, take them back to the doctor so that their arm can be evaluated again. Dislocation, isolated and with associated injuries are often seen between 10 and 15 years of age 2. Approximately 65% of all fractures in children are to the upper limb, with the vast majority the result of indirect forces, following a fall on the outstretched hand (Fig. The longer the elbow has been out of place, the more painful and difficult it is to put back into place, and the longer it takes to fully recover. Disruption of the posterior capsule may also occur and contribute to the risk of recurrent dislocation. The anterior capsule is commonly disrupted, exposing the articular surface and increasing the danger of soft tissue or neurovascular structures being interposed during reduction. The child may cry for a few minutes after successful reduction; analgesia is unnecessary. Severe ulnar nerve injury is less common now than previously described owing to the increasing recognition that entrapment of the medial epicondyle within the joint may also trap the ulnar nerve.18 Ulnar nerve injuries are usually transient. Fractures and Dislocations about the Elbow in the Pediatric Patient Amy L. McIntosh, MD . The Monteggia fracture dislocation is the most common fracture–dislocation combination in childhood (Fig. This may occur due to interposed tissue, of which incarceration of the medial epicondyle within the joint is by far the most common. Primary ligament repair is not an appropriate indication as studies have shown that the outcome is inferior to closed treatment. 13.6). The head of the radius subluxates distally but not beyond the equator, or maximal circumference, of the head. Sometimes, the child may take 30 minutes to resume moving his/her hand normally. In addition, the coronoid process is also at risk of fracturing. Kids Health Info is supported by The Royal Children’s Hospital Foundation. Tearing of the brachialis may expose the median nerve and brachial artery, which are then stretched directly over the trochlea. If a fracture has been identified or is suspected, access to fluoroscopy will normally dictate transfer to the operating theatre. Given that more than 50% of elbow dislocations in children have associated fractures, the radiographs must be carefully examined for bony injuries (medial epicondyle, radial neck and coronoid).19 Less common fractures include lateral condyle, lateral epicondyle, medial condyle and olecranon. This information is intended to support, not replace, discussion with your doctor or healthcare professionals. Open reduction is indicated for all displaced fractures and those demonstrating joint instability. 13.6A, B). Reduction of the dislocated elbow is the major treatment of a dislocated elbow. Inset (right to left): the annular ligament may be stretched or torn, and once traction is discontinued may subluxate into the radiocapitellar joint. Isolated dislocation of the radial head is uncommon. You will be advised if this is necessary. Recurrent episodes occur in 5–39% of children until the annular ligament becomes stronger and stiffer. The majority of elbow dislocations are managed by closed reduction. In addition, the coronoid process is also at risk of fracturing. The common causes of more severe stiffness are delayed diagnosis, immobilization beyond 3 weeks, and vigorous and early physiotherapy, particularly if this involves passive stretching and missed incarceration of the medial epicondyle necessitating delayed open reduction.25. Early mobilization of simple dislocations after closed reduction is associated with low risk of redislocation. Follow the advice of the nurse or doctor, or see our fact sheet Pain relief for children. Common injury in children 1-4 years of age as a result of a sudden pull on the arm (usually by an adult), which pulls the radius under the annular ligament. The examiner gently supinates the child’s forearm with one hand and applies gentle pressure over the radial head with the other. 13.5). 13.1).2 The most common site of injury is the wrist and hand, with the elbow region accounting for approximately 10% of the total. (A) AP and (B) lateral radiographs of the left elbow of a girl involved in a motor vehicle accident, demonstrating multi-trauma in a single arm: a fracture of the distal humerus and a Bado type 1 Monteggia fracture–dislocation of the forearm. This procedure is painful and distressing, but it only lasts a short moment and is over when the radial bone pops back into place. When the bones of the elbow are forced out of their normal position, it is called a dislocated elbow. The child regained satisfactory range-of-motion of the elbow with complete bony union within 3 months. 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