■ Case Report
An Unusual Case of Elbow Dislocation and a
Review of the Literature
NIKOLAOS LASANIANOS, MD; CHRISTOS GARNAVOS, MD
T
he frequency of elbow disloca-
tion is second to that of shoul-
der dislocation in adults.1 Adult
elbow dislocations are classified by the
direction of displacement and associated
fractures. They can be anterior, posterior,
lateral, or divergent, with the most com-
mon type being posterior displacement of
both the radius and ulna in relation to the
distal humerus.1, 2 Associated injuries to
the shoulder, distal radius/ulna, and car-
pal bones occur in 10% to 15% of cases.3
Most dislocations happen after a fall on
an outstretched hand. Elbow dislocations
and fractures can also occur with a high-
energy direct impact.1
This case report is about a nonclassified
type of elbow dislocation, the reduction ma-
neuver, the rehabilitation, and the final out-
come. From its radiograph appearance it was
named twisting dislocation of the elbow.
CASE REPORT
A 55-year-old woman experienced a fall
on her outstretched right arm. The right elbow
joint was swollen and painful and the forearm
pronated. There was no neurological or vascu-
lar deficit. Only 1 lateral radiograph was per-
formed, as the patient’s painful state did not
allow for an anteroposterior view. The radio-
graph revealed an unusual twisting dislocation,
with both the humerus and the ulna being ro-
tated by 90° and 180° respectively (Figure 1).
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Figure 1: Lateral radiographic view of a twisting
elbow dislocation.
After infiltrating 7 ml of regional anesthetic
(Xylocaine 2%) into the dislocated elbow,
closed reduction was performed by applying
gentle external rotation to the distal humerus
while an assistant was simultaneously supinat-
ing the forearm. The elbow joint was immo-
bilized at 90° of flexion. Anteroposterior and
lateral radiographs confirmed the reduction
(Figure 2).
The elbow was put in a cast in 90° of flex-
ion with the forearm slightly pronated for 3
days. On the third day the cast was replaced
by a functional brace, which remained for 3
weeks. The brace allowed free range of flexion
and extension but blocked pronation and supi-
nation of the forearm. The patient was encour-
aged to move the elbow with the brace, and no
additional physiotherapy was initiated. Weight
2A 2B
Figure 2: Anteroposterior (A) and lateral (B) views
of a twisting elbow dislocation post-reduction.
lifting was prohibited. At 3 weeks follow-up,
the patient had regained a flexion-extension
range of motion (ROM) from 40° to 110° (Fig-
ure 3). Pronation and supination were limited
to a -40° to +40° range. At that point the brace
was removed and specific self-executed exer-
cises were taught. At 5 weeks follow-up, the
elbow joint was painless with full range of
motion (Figure 3), and the patient was advised
to return to her normal activities. At the final
Drs Lasanianos and Garnavos are from the
Orthopaedic Department, Evangelismos General
Hospital, Athens, Greece.
Financial disclosure.
Correspondence should be addressed to:
Nikolaos Lasanianos, MD, 12 Lontou St, Palea
Penteli, 15236, Athens, Greece.
1
7/10/2008 3:41:32 PM
 ■ Case Report
follow-up 1 year later, the elbow was pain-free
even when stretched. The varus-valgus stress
of the joint did not reveal any sign of instabil-
ity. No periarticular calcification was noted.
DISCUSSION
The annual incidence of elbow disloca-
tion is 6 to 8 cases per 100,000 in the US;
these dislocations represent 11% to 28%
of all injuries to the elbow. The frequency
of elbow dislocation is second to that of
shoulder dislocation.3
The stabilizing structures of the elbow
can be thought of as a ring.4 The trochlear
notch surrounds almost 180⬚ of the troch-
lea, accounting for a large part of the sta-
bility of the elbow joint. The ulnohumeral
articulation has been shown to be the most
important stabilizer of the elbow joint.
The posterior column, the disruption of
which would be a prerequisite for anterior
dislocation, is formed by the olecranon,
the triceps, and the posterior aspect of the
capsule, whereas the anterior column is
formed by the coronoid process.4
The medial collateral ligament and lat-
eral collateral ligament comprise the liga-
mentous stability of the elbow and act as a
backup system to the elbow’s natural bony
stability. The medial collateral ligament
consists of 3 bands: the anterior oblique,
the posterior oblique, and the transverse.
The anterior band provides most of the
resistance to valgus stress. The lateral col-
lateral ligament has 2 bands: the ulnar col-
lateral and the radial collateral.1
Adult elbow dislocations are classified
by the direction of displacement and as-
sociated fractures. Simple elbow disloca-
tions are solely soft tissue injuries. The di-
rection can be anterior, posterior, lateral,
or divergent. Usually elbow dislocations
involve posterior displacement of both the
radius and ulna in relation to the distal hu-
merus.1
The most common accompanying
bony injury of an elbow dislocation is a
fracture of the olecranon process (20%),
while coronoid process fracture occurs in
10% to 15% of the cases.1 The supracon-
2 ORTHOPEDICS | ORTHOSuperSite.com
ORTHO0808Lasanianos.indd 2
3A
3C
Figure 3: 110° extension of the elbow 3 weeks post-reduction (A), 40° flexion of the elbow 3 weeks post-
reduction (B), full extension of the elbow 5 weeks post-reduction (C), and full flexion of the elbow 5 weeks
post-reduction (D).
dylar humerus, capitellum, and trochlea
are fractured less frequently.
Simple elbow dislocations are reduced
under local anesthesia in the emergency
room. General anesthesia is reserved for
difficult irreducible dislocations.5-7
The rehabilitation of elbow dislocation
ranges from aggressive immediate active
motion to traditional plaster of Paris (POP)
immobilization for several days. Forceful
passive mobilization in the rehabilitation
period must be avoided, since the elbow
joint has a natural tendency to develop
myositis ossificans following passive ma-
nipulation.8 Twenty years ago, authors
were suggesting a period of immobiliza-
tion for up to 2 weeks.9-11 Mehlhoff et al12
proposed that gentle, active flexion should
begin as soon as pain allows, and unpro-
tected flexion-extension should be initi-
ated sooner than 2 weeks post-injury. The
natural stability of the elbow joint against
dislocation recurrence results primarily
from its bony architecture, reinforced by
the medial and lateral thickening of the
capsule.13 The success of nonoperative
management is thus explained by the sta-
bilizing effect of joint surfaces, particu-
larly during ligamentous healing.14
Surgical repair of the elbow collateral
3B
3D
ligaments has been advocated, but there
is little evidence that the results of such
a repair are any better than those of non-
surgical treatment.14 The disadvantages
of immobilization have been widely rec-
ognized (eg, pain, persistent stiffness, late
degenerative changes, etc).15-17 Mehlhoff
et al,12 Josefsson et al,14 and Coonrad et
al18 agree that elbow stiffness has been the
most common complication following dis-
location. Now most authors recommend
immediate accelerated functional treat-
ment for simple elbow dislocations,10,18-20
as long periods of immobilization may be
harmful.21 Ross et al20 used a specific pro-
tocol after closed reduction without any
immobilization and achieved 95% suc-
cess. Protzman11 suggested immediate re-
duction followed by 1 to 5 days of immo-
bilization for uncomplicated dislocations.
In our case, the elbow was in a cast for 3
days for the swelling to subside, allowing
the patient to become familiar with the re-
habilitation program that would follow.
It seems there will always be unusual or
unclassifiable types of injuries that will con-
firm the unwritten rule of the unlimited
variation of mechanisms that produce an
equally endless number of injury modalities.
The elbow dislocation presented in this case
7/10/2008 3:41:34 PM

report is another example of a unique type of
injury that, to our knowledge, has not been
previously described in the literature. Re-
gardless of the custom-made manipulation
required for its reduction, the immediate ac-
tive mobilization of the joint resulted in an
excellent outcome.
REFERENCES
1. Halstead M. Elbow dislocation. eMedicine
from WebMD Web site. http://www.emedi-
cine.com/sports/TOPIC31.HTM. Updated
April 25, 2007. Accessed April 25, 2008.
2. De Palma A. Dislocations of the elbow
joint. In: De Palma A, ed. The Management
of Fractures and Dislocations: An Atlas.
Philadelphia, PA: WB Saunders Company;
1970:724-754.
3. Hildebrand KA, Patterson SD, King GJ.
Acute elbow dislocations: simple and com-
plex. Orthop Clin North Am. 1999; 30(1):63-
79.
4. Ring D, Jupiter JB. Fracture-dislocation
of the elbow. J Bone Joint Surg Am. 1998;
80(4):566-580.
5. Exarchou EJ. Lateral dislocation of the el-
bow. Acta Orthop Scand. 1977; 48(2):161-
163.
6. Pawlowski RF, Palumbo FC, Callahan JJ.
Irreducible posterolateral elbow disloca-
AUGUST 2008 | Volume 31 • Number 8
ORTHO0808Lasanianos.indd 3
ELBOW DISLOCATION | LASANIANOS & GARNAVOS
tion: report of a rare case. J Trauma. 1970; 15. Habernek H, Ortner F. The influence of ana-
10(3):260-266. tomic factors in elbow joint dislocation. Clin
Orthop Relat Res. 1992; (274):226-230.
7. Chhaparwal M, Aroojis A, Divekar M,
Kulkarni S, Vaidya SV. Irreducible lateral 16. Salter RB. The biologic concept of continu-
dislocation of the elbow. J Postgrad Med. ous passive motion of synovial joints. The
1997; 43(1):19-20. first 18 years of basic research and its clini-
cal application. Clin Orthop Relat Res. 1989;
8. Watson-Jones R. Fractures and Joint Injuries.
(242):12-25.
Vol 2. 6th ed. London, England: Churchill
Livingstone; 1982. 17. Salter RB. The physiologic basis of con-
tinuous passive motion for articular cartilage
9. Borris LC, Lassen MR, Christensen CS.
healing and regeneration. Hand Clin. 1994;
Elbow dislocation in children and adults.
10(2):211-219.
A long-term follow-up of conservatively
treated patients. Acta Orthop Scand. 1987; 18. Coonrad RW, Roush TF, Major NM, Ba-
58(6):649-651. samania CJ. The drop sign, a radiographic
warning sign of elbow instability. J Shoulder
10. Lansinger O, Karlsson J, Körner L, Måre K.
Elbow Surg. 2005; 14(3):312-317.
Dislocation of the elbow joint. Arch Orthop
Trauma Surg. 1984; 102(3):183-186. 19. O’Driscoll SW, Morrey BF, Korinek S, An
KN. Elbow subluxation and dislocation. A
11. Protzman RR. Dislocation of the elbow joint.
spectrum of instability. Clin Orthop Relat
J Bone Joint Surg Am. 1978; 60(4):539-541.
Res. 1992; (280):186-197.
12. Mehlhoff TL, Noble PC, Bennet JB, Tullos
20. Ross G, McDevitt ER, Chronister R, Ove PN.
HS. Simple dislocation of the elbow in the
Treatment of simple elbow dislocation using
adult. Results after closed treatment. J Bone
an immediate motion protocol. Am J Sports
Joint Surg Am. 1988; 70(2): 244-249.
Med. 1999; 27(3):308-311.
13. Neviaser JS, Wickstrom JK. Dislocation of
21. Riel KA, Bernett P. Simple elbow disloca-
the elbow: a retrospective study of 115 pa-
tion. Comparison of long-term results after
tients. South Med J. 1977; 70:172-173.
immobilization and functional treatment [in
14. Josefsson PO, Gentz CF, Johnell O, Wende- German]. Unfallchirurg. 1993; 96(10):529-
berg B. Surgical versus non-surgical treat- 533.
ment of ligamentous injuries following dis-
location of the elbow joint. A prospective
randomized study. J Bone Joint Surg Am.
1987; 69(4):605-608.
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