The elbow is the second most frequently dislocated joint in adults, following the shoulder, and is the most common joint dislocation in children. Elbow dislocations can be categorised as either simple or complex; complex dislocations involve fractures of the radial head or neck, olecranon, coronoid, or the condyles and epicondyles of the humerus. This article will concentrate on the initial management and rehabilitation of simple elbow dislocations.
Elbow Anatomy
The stability of the elbow joint relies on the congruence of the bony structures, supporting ligaments, and the muscles that traverse the joint. The primary stabilisers include the bony connections between the ulna and humerus, along with the medial and collateral ligaments. Secondary stabilisers consist of the radial head, anterior capsule, and associated muscles.
Injury Mechanisms
Dislocations often occur due to significant axial forces or falls onto an outstretched hand, with about 40% of cases resulting from sports injuries. Elbow dislocations can be further classified by their direction—either anterior or posterior— and can also be subdivided into medial or lateral variations. The most prevalent dislocation pattern is posterolateral.
Despite being labeled "simple," these elbow dislocations actually reflect a complicated injury involving the capsuloligamentous structures of the elbow. Two primary injury models have been proposed: one involves valgus, compression, and supination, leading to soft tissue damage from the lateral to medial side, termed the ‘Horii’ circle. The other, introduced by Scheiber and colleagues, suggests a valgus, hyperextension mechanism that first affects the medial ligament before involving the lateral ligament. Various studies, including MR imaging, radiographic assessments, cadaver analyses, and video reviews, indicate a broad range of soft tissue damage associated with elbow dislocations.
Initial Management
The immediate response to an elbow dislocation includes diagnosis via imaging and orthopedic reduction, usually conducted in an emergency setting. After reduction, further imaging is essential to confirm proper alignment, alongside clinical assessments to evaluate stability. The elbow must demonstrate stability throughout its range of motion to be deemed clinically stable, enabling safe early mobilisation. If significant instability persists post-reduction, follow-up with an orthopedic specialist within a few days is necessary, and MR imaging may be recommended to assess ligament integrity. In cases of severe instability with compromised ligaments, surgical intervention might be required. Given the diverse nature of soft tissue damage after dislocation, patient outcomes can vary significantly.
Once a stable reduction is achieved, conservative (non-surgical) management is widely regarded as the best approach for simple elbow dislocations. Historically, this involved immobilisation in a plaster cast for three weeks post-injury. However, current best practices advocate for early mobilisation. This method allows for sling usage and/or bandaging outside of physical therapy sessions.
A systematic review conducted in 2020 evaluated randomised control trials comparing outcomes of immobilisation versus early mobilisation. Results indicated that the early mobilisation group experienced a quicker return of full active range of motion, as well as an earlier return to work and sports. However, this group also reported higher pain levels during the first six weeks compared to the immobilisation group. By the 12-month follow-up, only one study demonstrated superior outcomes in the early mobilisation group, while other studies showed similar results between both groups. Redislocation rates remained low and comparable in both groups, with the early mobilisation group exhibiting a reduced incidence of heterotopic ossification.
Rehabilitation Protocols
Several studies in the 2020 systematic review outlined rehabilitation protocols to follow during the early mobilisation phase, starting two days post-dislocation. These protocols should be implemented under the guidance of orthopedic specialists and physiotherapists.
Early Mobilisation Protocol:
Weeks 0-3: Protected ROM (Supine Position) Exercises should be performed in a supine position with the shoulder flexed to 90 degrees and adducted, minimizing gravitational effects. The following exercises can be done in this position:
A: Elbow flexion
B: Elbow extension
C: Supination (twisting palm upward)
D: Pronation (twisting palm downward)
These exercises can be performed without range of motion restrictions, guided by the patient’s tolerance.
Weeks 3-6: Full Active ROM (Dependent Position) Once joint stability is confirmed via lateral extension radiographs, the sling can be removed, and full active range of motion exercises can begin in a dependent position, guided by the patient’s comfort and stability.
Week 6 and Beyond: Full ROM and Strengthening After six weeks, patients can move through their full range of motion without restrictions and begin strength and endurance training. The objective of this progressive exercise therapy is to restore strength, proprioception, and stability. Patients can typically resume normal activities, such as driving and work, although return to high-demand sports may take longer.
Role of Physiotherapy
Physiotherapists play a crucial role in guiding patients with elbow dislocations through these rehabilitation protocols. Since rehabilitation programs should be tailored to individual needs, physiotherapists will continuously monitor progress and adjust plans based on healing, stability, and pain levels.
From the six-week mark, physiotherapists will introduce strengthening exercises targeting the muscles crossing the elbow and the broader kinetic chain. All exercise programs should be developed collaboratively with patients, considering their progress and personal goals. The timeline for returning to demanding work or sports varies based on each patient’s rehabilitation progress and activity requirements.
Conclusion
Simple elbow dislocations, though termed "simple," represent significant capsuloligamentous injuries with varying degrees of soft tissue damage. Once a stable reduction is achieved, early mobilisation is recommended as best practice. This approach consists of three weeks of protected range of motion, followed by three weeks of full active range of motion. After six weeks, patients can resume normal activities without restrictions and begin progressive strengthening exercises, with return to work and sports guided by the rehabilitation team based on individual progress and demands. All rehabilitation should be conducted under the oversight of a physiotherapist and orthopedic specialist.
Comments