Dislocations of the Elbow

Dislocations of the Elbow

The elbow is typically a stable joint that requires significant force to alter its integrity and cause dislocation. Therefore, a good number of dislocations are often accompanied by concomitant fractures. The elbow joint is susceptible to anterior and posterior dislocation, the latter being the most widespread. With anterior dislocations, significant force is typically directed at the posterior aspect of a flexed elbow. This mechanism of injury causes the olecranon to move anterior to the humerus. In the most common posterior dislocation, the mechanism of injury is often described as a fall on an outstretched arm. This condition usually presents in an obvious deformity with an exaggerated swelling of the olecranon in the back. Clinical symptoms of both dislocations include severe focal pain in the elbow joint and rapid onset of effusion. Emergency medical care should consist of immobilizing the anatomy in the presentation position with a rigid, pneumatic, or vacuum splint. Due to the complexity of the elbow joint, these dislocations often accompany a high incidence of neurovascular impairment and associated fractures. Therefore, it is strongly recommended that only competent orthopedic specialists perform site-specific reductions. Therefore, elbow joint dislocations require immediate EMS activation for full care and transportation to the nearest medical facility. While waiting for the EMS, the athletic trainer must periodically monitor the neurovascular status. Complications resulting from improper management include brachial artery occlusion, medial or ulnar nerve pathology, myositis ossifying, and arthritis. The fitness coach must also be aware of the possibility of spontaneous reduction of the dislocation and remain alert for the warning signs of any of the complications mentioned above. If spontaneous reduction of a dislocation is suspected, the fitness trainer should evaluate the stability of the elbow complex and adequately fix the area. The injured athlete must also be transported immediately to the nearest emergency medical facility for appropriate follow-up care.

Dislocations of the Shoulder

Of large articulations throughout the human skeletal system, the GHJ is one most predisposed to dislocate during athletic activities.8 The majority of GHJ dislocations are described as anterior and posterior. Inferior dislocations

are typically associated with concomitant fracture and significant neurovascular compromise, although such injuries are rare. Glenohumeral joint dislocations are widespread in contact or collision sports participation and are often the result of direct trauma. The mechanism of injury most

often eliciting an anterior dislocation is that of a direct extreme external rotation and abduction force applied to the GHJ. Posterior dislocations of the GHJ occur as the result of a significant direct force that drives the humeral

head posteriorly, thereby disrupting its integrity with the glenoid. Athletes sustaining GHJ dislocations often present with a significant amount of pain and tendency to cradle the injured extremity. There is also an unwillingness and inability to generate range of motion within the affected shoulder complex. Assessing a GHJ dislocation is best accomplished through visual inspection of the involved anatomy for obvious deformity. This usually consists of an exaggerated protrusion of the humeral head and hollow

area inferior to the acromion.

Emergency medical care of GHJ dislocations should begin with a thorough examination to rule out associated neurovascular compromise and potentially related fractures. Significant spasm of surrounding musculature is usually quickly noted subsequent to GHJ dislocations. This protective guarding mechanism can pose a considerable challenge in reducing the joint dislocation. Prompt competent joint reduction on the field of play typically necessitates less force. Furthermore, early reduction can provide considerable relief from pain in addition to diminishing the potential for iatrogenic pathology.Although ideally radiographic images of the injured joint should be obtained prior to and following reduction to rule out related fractures, the benefits of early reduction usually outweigh the involved risks. This is especially evident in those individuals suffering from chronic  GHJ instability and recurrent dislocations. Within this particular population concomitant fractures rarely present. Three commonly used modes of reduction include the self-reduction technique, the gravity (modified Stimson’s) method, and traction/external rotation procedure. Selfreduction calls for the athlete with a GHJ dislocation to interlock his or her fingers and grasp the flexed knee of the unaffected side. The athlete then gradually leans backward, inducing slight traction to the GHJ, which ideally yields relocation.

The gravity (modified Stimson’s) method requires the athlete to lay prone with the injured extremity draped over an examination table or similar surface. The athletic trainer then grasps the wrist of the affected extremity and applies a minimal amount of gravity-assisted traction. The gravityassisted traction aims to gradually stretch the surrounding musculature in spasm, thereby facilitating relocation of the

GHJ.

The traction/external rotation procedure begins with the injured athlete in a supine position followed by the athletic trainer inducing mild and continual traction along the significantly decrease pain. The athletic trainer then slowly

and passively guides the GHJ to approximately 90 degrees of abduction while maintaining the mild traction. Once this has been accomplished the GHJ should be gradually externally rotated to correct physiological terminal range. This position is held steadily to relieve muscle spasm. Once the protective muscle spasm has been decreased, the GHJ dislocation should reduce spontaneously and be felt by both the injured athlete and athletic trainer. If reduction in this position proves unsuccessful, the clinician may attempt to  gradually increase GHJ abduction to 120 degrees while steadily maintaining traction and GHJ external rotation.

athletic trainer must remain cognizant that aggressive traction

or countertraction is not used in this joint reduction

mode.36 Following relocation of the articulation, the GHJ is

returned to 0 degrees of abduction and internally rotated

until the hand comes into contact with the torso, all while

maintaining steady traction.

It is imperative the athletic trainer periodically reassess

neurovascular functions following reduction. An arm sling

should be used for comfort,with careful application of ice for

pain control.8,37 Referral to an orthopedic specialist for urgent

consultation is highly recommended following GHJ dislocations.

If a GHJ dislocation cannot be reduced easily, it must

be appropriately splinted in a position of comfort and the

injured athlete must be transported to a hospital by EMS.