Stable, unstable elbow dislocations may benefit from nonoperative treatment
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WAILEA, Hawaii — Patients with stable or unstable elbow dislocations can usually be treated nonoperatively, according to a presenter at Orthopedics Today Hawaii.
Although some patients with elbow dislocations have significant trauma, Joseph A. Abboud, MD, said other patients can be ligamentously laxed with dislocations caused by minor or moderate activity.
“As long as [the patient has] a concentric reduction and they’re able to keep their elbow in early on, then I think it bodes well for their management,” Abboud said in his presentation.
Abboud noted he tries to see patients with elbow dislocations frequently.
“Oftentimes, I’ll see them right after the injury at 3 to 5 days, then I’ll see them again a week later,” Abboud said.
He added he will keep patients in a splint at about –30° of extension and provide an extension block. When patients with an elbow dislocation also present with a fracture, Abboud said he orders a CT scan which will not only allow for assessment of the fracture, but also assessment of the concentricity of the reduction.
While patients with stable elbows after reduction of their dislocation receive a splint, patients with unstable elbows will be pronated if the medial collateral ligament is intact to help with stabilization, according to Abboud. After stabilization, Abboud noted patients will then usually receive a splint followed by a hinged brace as they begin motions with flexion and extension.
“If they remain unstable despite blocks of extension and they have to go to greater than 30° of [extension] blocks, then that’s when you’re starting to talk about surgery, either repair or reconstruction,” Abboud said.
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This interesting presentation by Joseph A. Abboud, MD, confirms many of the conventional beliefs that most cases of simple elbow dislocation may be treated nonoperatively. Since the 1980s, when randomized trials showed that there was no consistent surgical benefit of open repair of ligamentous injuries from isolated or simple elbow dislocations, the standard of care has been a closed reduction and early motion.
As Abboud points out, many of these individuals will have significant disruption laterally but an intact medial collateral ligament and, in those individuals, forearm pronation helps hold the elbow reduced. If a simple elbow dislocation (ie, with no associated fractures) demonstrates early instability (re-dislocation or unacceptable subluxation), then surgical repair is usually indicated rather than re-reduction and prolonged immobilization. Surgical repair in this setting typically focuses on the lateral-sided structures. As Abboud also points out, a CT scan is an excellent way of not only demonstrating associated fractures (an elbow fracture/dislocation has a higher requirement for surgical intervention), but also assessing for joint congruency.
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