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CASE REPORT

I. IDENTITY
Name : Mrs. Kartini Syaid
Age : 30 years
Sex : Female
Religion : Muslim
Address : Sumur Jodoh Street. No. 25 Pare Pare
Marriage status : Married
RM : 125937
Admission date : March 13th 2017

II. ANAMNESIS
Chief complaint :Pain at left elbow
Patient came to the emergency room of A.Makassau hospital with chief
complaint of pain in the right elbow Since 4 hours before admitted to hospital
due to traffic accident. Patient was riding a motorcycle then suddenly hit by a
car from opposite direction. There is history of decreased level of
consciousness, no vomit.
Past History : Hypertension and Diabetes Mellitus was denied
Social economic history : BPJS

III. PRIMARY SURVEY

 Airway and C-spine control
 Patent
 Breathing and Ventilation
 RR = 20 x/minute, reguler, spontaneous, thoracoabdominal type,
symmetric

 Circulation and Hemorrhagic Control
 BP = 110/70 mmHg, HR = 90 x/minute, reguler, strong pulse, CRT
<2second
 Disability and Neurology Evaluation
 GCS 15 (E4M6V5), pupil isochor, Ø 2.5 mm/2.5 mm, light reflex +/+
 Exposure and Environment Control
 Axilla temperature= 36.8oC

IV. SECONDARY SURVEY:
Right Elbow Joint

Look :

Wound(-), Deformity (+),Swelling (+), Hematoma (-).

Feel :

Tenderness (+)

Move:

Active and passive movement of Right elbow joint was limited due to
pain.

NVD:

Sensibility is good, CRT < 2 seconds, pulsation of radialis artery is
palpable

V. CLINICAL FINDINGS

RADIOGRAPHY  X-Ray Elbow AP on March 13th 2017 .VI.

Patient being treated in hospitals Andi Makassau and planned to operated. no history of vomit. active and passive movement of right elbow joint was limited due to pain. was admitted to hospital on March 13 th 2017 with pain in the right elbow since 4 hours ago. Tenderness (+). RESUME Patient female. Range of motion.VII. Sensibility is good. There was decreased level of consciousness. pulsation of radialis artery and ulnaris artery is palpable. Radiologic examination of antebrahii AP/Lateral . 30 years old. CRT < 2 seconds. In physical examination of right elbow joint there ais deformity. Patient was riding a motorcycle with her husband from hospitals to go home then suddenly hit by a car from opposite direction.

IVFD Ringer Lactate . DIAGNOSE  Right Lateral Elbow Dislocation IX. MANAGING .Closed Reduction under Narcose .VIII.Analgesic .

DISCUSSION Anatomy .

.

Flexion and extension : 0-1500 (functional ROM : 1000 [30-1300].]). axis is the trochlea. The Elbow comprises three articulations 1. Radiocapitellar (radial head and apitellum): Trochoid (pivot) joint. 2.  Two primary motions : 1. -500 sup. .. Pronosupination : 700 pro. axis is RC joint  Stability provided by combination of osseous (articulations) and ligamentous restraints. -800 sup. 2. 3. (functional ROM : 1000 [500 pro. Proximal radioulnar (radial head and lesser sigmoid notch)  Primary function is as a lever for lifting and placing the hand appropiately in space. carrying angle 11-160 valgus. Ulnohumeral (trochlea and greater sigmoid notch): Ginglymus (hinge) joint.

Full extension provides 30% of valgus stability. . Valgus: The medial collateral ligament (MCL) complex . coronoid fossa. Three separate articulations are:  Ulnotrochlear (hinge)  Radiocapitellar (rotation)  Proximal radioulnar (rotation) Anterior-posterior: trochlea-olecranon fossa (extension). radiocapitellar joint. and ligamentous constraints. Varus: The lateral ulnar collateral ligament is static. biceps-triceps-brachialis (flexion). Ninety degrees of flexion provides >50% of valgus stability. Function of the MCL . opposing tension of triceps and flexors. especially the anterior band. Anterior band is the primary stabilizer in flexion and extension. Anterior capsule and radiocapitellar joint function in extension. . . and the anconeus muscle is dynamic stabilizer. The anterior joint capsule is also felt to play a role in ulnohumeral stability. . ANATOMY The elbow is a “modified hinge” joint with a high degree of intrinsic stability owing to joint congruity. Primary medial stabilizer.

. and 80 degrees pronation. 85 degrees supination. Normal range of motion: 0 to 150 degrees flexion. and 50 degrees pronation. Resection of anterior band will cause gross instability except in extension. Functional range of motion (ROM) requires: a 100-degree arc. More recent reports suggest . Lateral ligaments Prevent posterior subluxation and rotation of the ulna away from the humerus with the forearm supinatio (posterolateral rotatory instability). 50 degrees supination. 30 to 130 degrees flexion.

the deformity is obvious. several fractures) will render the joint more unstable and. Disruption of the capsule and ligaments structures alone can result in posterior or posterolateral dislocation. Injuries are usually classified according to the direction of displacement. DISLOCATION OF THE ELBOW Dislocation of the ulno-humeral joint is fairly common – more so in adults than in children. Once posterior dislocation has taken place. worse still. The result is forward dislocation with fractures of any or all of the bones around the elbow. typically.increased ROM is needed to perform contemporary activities of daily living such as talking on a cell phone or using a computer mouse and keyboard. However. highenergy injuries do not necessarily follow any rules. unless the fractures are reduced and fixed. liable to redislocation. is struck by another vehicle. The bony landmarks (olecranon and epicondyles) may be palpable and abnormally placed . A classic example is the so-called side-swipe injury which occurs. lateral shift may also occur. Unless swelling is severe. Although certain common patterns of fracture-dislocation are recognized (based on the particular combination of structures involved). when a car- driver’s elbow. However. Clinical features The patient supports his forearm with the elbow in slight flexion. often together with fractures of the restraining bony processes. Soft tissue disruption is often considerable and surrounding nerves and vessels may be damaged. reduction will usually be stable and recurrent dislocation unlikely. in 90% of cases the radioulnar complex is displaced posteriorly or posterolaterally. protruding through the window. Mechanism of injury and pathology The cause of posterior dislocation is usually a fall on the outstretched hand with the elbow in extension. provided there is no associated fracture. coronoid process or olecranon process (or. The combination of ligamentous disruption and fracture of the radial head. soft-tissue damage (including neurovascular injury) is usually severe.

A. .

Dislocation of the elbow X-rays showing (a) lateral and (b) posterior displacement.000 population per year. However. Treatment EPIDEMIOLOGY  Elbow dislocation accounts for 11% to 28% of elbow injuries. It is often only when the elbow is screened at the time of surgery that the full extent of the injury can be established. accounting for 80% to 90% of all elbow dislocations.  Annual incidence of elbow dislocations is 6 to 8 cases per 100. Nevertheless. B.  Posterior dislocation is most common. in severe injuries pain and swelling are so marked that examination of the elbow is impossible. . X-ray X-ray examination is essential (a) to confirm the presence of a dislocation and (b) to identify any associated fractures. the hand should be examined for signs of vascular or nerve damage.

to 20-year-old age group and is associated with sports injuries. After reduction. . Unless almost full flexion can be obtained. recurrent dislocation is uncommon. UNCOMPLICATED DISLOCATION The patient should be fully relaxed under anaesthesia. sideways displacement is corrected. In addition. After 1 week the patient gently exercises his elbow. The surgeon pulls on the forearm while the elbow is slightly flexed. The long-term results are usually good. The distal nerves and circulation are checked again.  Highest incidence occurs in the 10.  Complex dislocations are those that occur with an associated fracture and represent slightly less than 50% of elbow dislocations. at 3 weeks the collar and cuff is discarded. an x-ray is obtained to confirm that the joint is reduced and to disclose any associated fractures. the elbow should be put through a full range of movement to see whether it is stable. then the elbow is further flexed while the olecranon process is pushed forward with the thumbs. the olecranon is not in the trochlear groove. The arm is held in a collar and cuff with the elbow flexed above 90 degrees. Simple dislocations are purely ligamentous. With one hand. Elbow movements are allowed to return spontaneously and are never forced.

Medial epicondyle An avulsed medial epicondyle is. A benign enough injury. then fixation is usually needed. a medial ligament disruption. If the epicondylar fragment is displaced. stability is restored only by healing or repair of the ligaments and restoration of the radial pillar – either by fracture fixation or (in . it must be reduced and fixed back in position. This is usually not repaired surgically. for practical purposes. after 3 weeks movements are begun under supervision. but it can represent a substantial soft-tissue injury of the elbow. as the elbow remains stable Type III A single or comminuted fracture involving more than 50 per cent. If the elbow is unstable after reduction. The arm and wrist are splinted with the elbow at 90 degrees. DISLOCATION WITH ASSOCIATED FRACTURES Coronoid process Coronoid fractures have been classified by Regan and Morrey as: Type I Avulsion of the tip. Head of radius The combination of ligament disruption and a type II or III radial head fracture is an unstable injury. Type II A single or comminuted fracture of the coronoid with 50 per cent or less involved.

a large piece of the olecranon is left behind as a separate fragment. the elbow can completely dislocate with the anterior band of the MCL . MECHANISM OF INJURY Most commonly caused by a fall onto an outstretched hand or elbow. The capsuloligamentous injury progresses from lateral to medial (Hori circle) (Fig. resulting in a levering force to unlock the olecranon from the trochlea combined with translation of the articular surfaces to produce the dislocation. valgus stress. arm abduction. skeletal stabilization and soft tissue coverage. The medial collateral ligament may also be repaired to protect the radial head fixation or implant from undue valgus stress.the case of a comminuted fracture) by prosthetic replacement of the radial head. Persistent instability In cases where the elbow remains unstable after the bone and joint anatomy has been restored. Side-swipe injuries These severe fracture-dislocations are often associated with damage to the large vessels of the arm. Most elbow dislocations and fracture-dislocations result in injury to all the capsuloligamentous stabilizers of the elbow joint.2). the olecranon process may fracture. The exceptions include transolecranon fracture-dislocations and injuries with fractures of the coronoid involving nearly the entire coronoid process. The priorities are repair of any vascular injury. 18. Anterior dislocation: A direct force strikes the posterior forearm with the elbow in a flexed position. This is demanding surgery. necessitating a high level of expertise. and is best undertaken in a unit specialising in upper limb injuries. Posterior dislocation: This is a combination of elbow hyperextension. Open reduction with internal fixation is the best treatment. and forearm supination. Olecranon process In the rare forward dislocation of the elbow. a hinged external fixator can be applied in order to maintain mobility while the tissues heal.

Following manipulation or reduction.remaining intact. if arterial flow is not reestablished and the hand remains poorly perfused. Angiography may be necessary to evaluate vascular compromise. which shows variable gross instability and swelling. Serial neurovascular examinations should be performed when massive antecubital swelling exists or when the patient is felt to be at risk for compartment syndrome. A careful neurovascular examination is essential and should be performed before radiography or manipulation. repeat neurovascular examination should be performed to assess neurovascular status. CLINICAL EVALUATION Patients typically guard the injured upper extremity. There is a variable degree of injury to the common flexor and extensor musculature. the patient should be prepared for arterial reconstruction . Following reduction.

Anterior . Posterolateral . Lateral . Valgus stress views at 30 degrees elbow flexion and full forearm pronation. Acute neurovascular injuries are uncommon. 18. is typically apparent 3 to 5 days after injury. Radiographs should be scrutinized for associated fractures about the elbow.with saphenous vein grafting. ASSOCIATED INJURIES Associated fractures most often involve the radial head and/or coronoid process of the ulna. Angiography should be performed in the operating room and should never delay operative intervention when vascular compromise is present. Shear fractures of the capitellum and/or trochlea are less common. obtained after initial reduction or at surgery. Posterior . Computed tomography (CT) scans may help identify bony fracture fragments not visible on plain radiographs. Posteromedial . Congruence of the ulnohumeral and radiocapitellar joints should be assessed. may help identify an MCL injury. Medial .3): . The brachial artery may be injured. Medial ecchymosis. RADIOGRAPHIC EVALUATION Standard anteroposterior and lateral radiographs of the elbow should be obtained. CLASSIFICATION Simple versus complex (associated with fracture) According to the direction of displacement of the ulna relative to the humerus (Fig. The absence of a radial pulse in the presence of a warm. the ulnar nerve and anterior interosseous branches of the median nerve are most commonly involved. particularly with an open dislocation. well-perfused hand likely represents arterial spasm. The radial pulse may be present with brachial artery compromise as a result of collateral circulation. a sign of MCL disruption.

a single or comminuted fragment involving >50% of the process .4): . Types I. a single or comminuted fragment involving 50% of the coronoid process or less . avulsion of the tip of the coronoid process . Associated medial or lateral epicondyle fracture (12% to 34%): They may result in mechanical block following closed reduction owing to entrapment of fragment. and III (Regan and Morrey). 18. based on size of fragment (Fig. Fracture-Dislocations Associated radial head fracture: These make up 5% to 11% of cases. Associated coronoid process fracture (5% to 10%): These are secondary to avulsion by brachialis muscle and are most common with posterior dislocation.Type I. II.Type II.Type III.

central. Much less commonly.Elbow dislocations that are associated with one or more intra-articular fractures are at greater risk for recurrent or chronic instability. the coronoid fracture can be one simple large fragment.Posterior olecranon fracture-dislocations The following observations may be useful in guiding treatment: Terrible triad injuries nearly always have a type I or II coronoid fracture including the anterior capsular attachment. including : Posterior dislocation with a fracture of the radial head Posterior dislocation with fractures of the radial head and coronoid process—the so-called “terrible triad” injury Varus posteromedial rotational instability pattern injuries associated with anteromedial facet of the coronoid fractures . the coronoid fracture is type III. and lesser sigmoid notch) with or without a tip fragment. Fracture-dislocations of the elbow usually occur in one of several distinct. recognizable injury patterns. or it can be more comminuted.Anterior olecranon fracture-dislocations . Types of Elbow Instability Posterolateral rotatory instability (elbow dislocations with or without associated fractures) Varus posteromedial rotational instability (anteromedial coronoid facet fractures) Olecranon fracture-dislocations . In the setting of an olecranon fracture-dislocation. it can be fragmented into two or three large pieces (anteromedial facet.

Posterolateral Rotatory Instability (Fig. Occurs during a fall onto the outstretched arm that create a valgus. May also be caused iatrogenically during a lateral approach to the elbow joint. and posterolateral rotatory force. The ulna and the forearm supinate away from the humerus and dislocate posteriorly. if the ulnar band of the lateral collateral ligament (LCL) is taken down and left unrepaired. Soft tissue injury proceeds from lateral to medial. 18. May result in injury to the radial head or coronoid.5) May range from radiocapitellar instability to complete ulnohumeral dislocation. with the anterior band of the MCL . axial.

positive pivot shift test. anterior and posterior capsule. lateral ulnar collateral ligament disrupted Type II : Perched condyles.being the last structure injured. This injury occurs without fracture to the radial head. anterior and posterior MCL disrupted GENERAL TREATMENT PRINCIPLES Restore the inherent elbow stability. Posterolateral instability begins with disruption of the ulna band of the LCL. Instability Scale (Morrey) Type I : Posterolateral rotatory instability. particularly the coronoid process. and posterior MCL disrupted Type IIIb : Posterior dislocation. Transolecranon Fracture-Dislocations (Anterior) Result from a direct blow to the flexed elbow. particularly in older osteopenic individuals. lateral ulnar collateral ligament. lateral ulnar collateral ligament. anterior and posterior capsule. or (3) an additional fracture of the coronoid at its base. resulting in potentially subtle radiographic findings.t is possible to dislocate the elbow with the anterior band of the MCL remaining intact. Posteromedial Rotational Instability Occurs with a fall onto the outstretched arm that creates a varus stress. most traumatic injuries result in avulsion of the ligament from the lateral humerus. varus instability. Varus. lateral ulnar collateral ligament. anterior and posterior capsule disrupted Type IIIa : Posterior dislocation. and posteromedial rotational force to the elbow. (2) fracture of the olecranon. Some authors suggest that these injuries may result from the same mechanism that usually creates elbow dislocations. axial load. Radiocapitellar contact is very important to the . grossly unstable. Restore the trochlear notch of the ulna. This results in fracture of the anteromedial facet of the coronoid process and (1) injury to the lateral collateral ligament. valgus instability.

MCL will usually heal properly with active motion. Loss of neurologic function . Simple Elbow Dislocation Nonoperative Acute simple elbow dislocations should undergo closed reduction with the patient under sedation and adequate analgesia. but the MCL rarely needs to be repaired. The trochlear notch (coronoid and olecranon). and lateral collateral ligament should be repaired or reconstructed. Alternatively. general or regional anesthesia may be used. The lateral collateral ligament is more important than the MCL in the setting of most cases of traumatic elbow instability. reduction should be performed with the elbow flexed while providing distal traction. For posterior dislocations. Neurovascular status should be reassessed. followed by evaluation of stable range of elbow motion. Correction of medial or lateral displacement followed by longitudinal traction and flexion is usually successful for posterior dislocations (Fig. 18. radial head.6). and its repair is not necessary for stability.stability of the injured elbow.

After 6 weeks. Elbows that sublux in less than 30 degrees elbow flexion and full forearm pronation should be splinted with the elbow flexed 90 degrees and the forearm pronated. The LCL is addressed first. If pronation confers elbow stability. Recovery of motion and strength may require 3 to 6 months. which allows for a protected full ROM. Operative Surgery is indicated in elbows with instability when placed in >30 degrees elbow flexion. followed by placement of a hinged orthosis with forearm rotational control and an extension block. with progressive advancement of extension and rotation as stability permits.after closed reduction is rare but can be an indication for surgical exploration to rule out nerve entrapment. one can discontinue bracing and start physical therapy with terminal stretching. If instability is present in less than 30 degrees of elbow flexion. Elbows that are unstable in more than 30 degrees elbow flexion should be considered for surgical management. Elbows that are stable throughout the ROM should be splinted at 90 degrees flexion. the extremity should be splinted with the elbow flexed 90 degrees and the forearm pronated. followed placement of a hinged orthosis after 3 to 5 days. Hinged bracing is maintained for 6 weeks. elbows that sublux or dislocate during treatment. Postreduction radiographs are essential. one should pronate the forearm and reassess elbow stability. or those with associated unstable fractures. One could also consider use of hinged external fixation for persistent instability. followed by reassessment of stability. Surgery usually involves open reduction and repair of soft tissues back to the distal humerus. Close radiographic evaluation is needed to assess elbow reduction. . followed by placement of a hinged orthosis after 3 to 5 days that maintains forearm pronation. with reattachment using suture anchors or bone tunnels. Consideration of MCL repair is made if instability persists after LCL repair.

Absence of the radial pulse is a warning. Spontaneous recovery usually occurs after 6–8 weeks. this should be treated as an emergency. however. the brachial artery may have to be explored. Operative The operative measures include fixation or replacement of the radial head and lateral collateral ligament repair. COMPLICATIONS Complications are common. If there are other signs of ischaemia. an arteriogram is performed. some are potentially so serious that the patient with a dislocation or a fracture. Nerve injury The median or ulnar nerve is sometimes injured. . Splints must be removed and the elbow should be straightened somewhat. Most authors do not advocate acute MCL reconstruction. Patients who elect nonoperative treatment need to be aware of the potential for instability and the substantial potential for restriction of motion or arthrosis from the radial head fracture. EARLY Vascular injury The brachial artery may be damaged. When the lateral collateral ligament is repaired. but up to 10 days of immobilization is reasonable. Elbow Fracture-Dislocations in General Nonoperative The ability to meet treatment goals with nonoperative treatment is rare and surgery is indicated in most fracture-dislocations about the elbow. do stress the importance of the lateral collateral ligament to elbow stability and advocate reattachment of this ligament to the lateral epicondyle. If there is no improvement. Most authors. immediate active motion is usually possible (particularly if radiocapitellar contact has also been restored).dislocation of the elbow must be observed with the closest attention.

e. usually associated with forceful reduction and overenthusiastic passive movement of the elbow. but it is as well to be alert for signs such as slight swelling. . If the condition is suspected. however the precise pathogenesis is not known. i. In the management of all elbow injuries the joint should be moved as soon as possible. For injuries requiring prolonged splintage. It is due to muscle bruising or haematoma formation. a hinged elbow brace. with due consideration to stability of the fractures and soft tissues and without undue passive stretching of the soft tissues. or on some occasions a hinged external fixator. has well-defined cortical margins and trabeculae (as seen on x-ray). Persistent stiffness of severe degree can often be improved by anterior capsular release. exercises are stopped and the elbow is splinted in comfortable flexion until pain subsides. though not before the bone is fully ‘mature’. soft- tissue ossification is usually not visible until 4–6 weeks after injury. However. The most common cause of undue stiffness is prolonged immobilization. Antiinflammatory drugs may help to reduce stiffness. operative treatment should not be rushed. which is usually undetectable on plain x-ray examination until a month or more after injury. excessive pain and tenderness around the front of the elbow. gentle active movements and continuous passive motion are then resumed. LATE Stiffness Loss of 20 to 30 degrees of extension is not uncommon after elbow dislocation. they are also used prophylactically to reduce the risk of heterotopic bone formation. Nowadays it is rarely seen. along with tardy recovery of active movements. remember that sometimes the stiffness is due to myositis ossificans. fortunately this is usually of little functional significance. Heterotopic ossification (myositis ossificans) Heterotopic bone formation may occur in the damaged soft tissues in front of the joint. X-ray examination is initially unhelpful. In former years ‘myositis ossificans’ was a fairly common complication of elbow injury. can allow some movement in the flexion-extension plane whilst protecting against collateral stress. A bone mass which markedly restricts movement and elbow function can be excised.

there is no satisfactory treatment. If recurrent elbow instability occurs. Recurrent dislocation This is rare unless there is a large coronoid fracture or radial head fracture. which predisposes to yet further stiffness. Osteoarthritis Secondary osteoarthritis is quite common after severe fracture- dislocations. or only the backward displacement corrected. leaving the olecranon process still displaced sideways. in the hope that the elbow will regain a useful range of movement. Unreduced dislocation A dislocation may not have been diagnosed. total elbow replacement can be considered. but a wide soft tissue release is required. Alternatively. Other than this. manipulative reduction is worth attempting but care is needed to avoid fracturing one of the bones. Open reduction can be considered. the condition can be left. . the patient can be offered an arthrodesis or an arthroplasty. If pain is a problem. the lateral ligament and capsule can be repaired or re-attached to the lateral condyle. A cast with the elbow at 90 degrees is worn for 4 weeks. Up to 3 weeks from injury. In older patients.

John C.Apley and Solomon’s Concise System of Orthopaedics and Trauma. 2010. 225- 228 3. 2th Edition. 112-114. Rajasekaran S.p. 2. US: 2015. p. 2012. Solomon L. REFERENCE 1. Tenth Edition. Thompson. Fourth edition.Philadelphia: Saunders Elsevier.p.775 . UK.et all. Leg and Knee in: Netter's Concise Orthopaedic Anatomy.. et all.Dislocations and fracture dislocations of the elbow In: Mercer's Textbook of Orthopaedics and Trauma.