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cute, traumatic elbow dislocations can usually beeduced by manual manipulation in most cases. Thoughare, cases of simple dislocation without associated frac-ures that cannot be reduced because of the interpositionf ruptured ligaments or muscles within the joint haveeen reported.2,4 We present the case of a 70-year-oldan with a posteromedial elbow dislocation in whomlosed manipulative reduction was attempted on 2 oc-asions, as well as under general anesthesia, but failed.uch a case has not yet been reported.

ASE REPORTA 70-year-old man presented to the emergency depart-

ent for painful swelling in the left elbow joint caused by aall on the ground with the elbow extended. He complainedf severe pain and disability of the arm. On examination,e found that the olecranon protruded posteromedially

Figure 1).Subcutaneous ecchymosis in the posteromedial joint

rea was detected. Severe pain prevented all movement ofhe elbow. Extensive edematous swelling surrounding thelbow was noticed, and no neurovascular abnormalitiesere found. A deformity of the elbow joint was present. Onalpation, the olecranon was found to be displaced to theosterior and medial side, and as a result of edema, theadial head and the medial epicondyle of the elbow couldot be palpated.

Plain radiographs showed posteromedial dislocation ofhe elbow joint without associated fractures (Figure 2).nalgesics and muscle relaxants were administered forain control, and reduction was subsequently attempted by

ongitudinal traction and forced flexion of the elbow joint.owever, despite 2 attempts at closed reduction, the elbow

oint could not be reduced. Because of concern thatxcessive manual manipulation might induce additionalamage to other structures and neurologic injuries, ad-itional manual manipulations were abandoned, andagnetic resonance imaging (MRI) was performed 8ours after admission.

The MRI results showed the posteromedial dislocation

rom aDepartment of Orthopaedic Surgery, Yon-sei University Col-lege of Medicine; and bDepartment of Orthopaedic Surgery,Daejean St Mary’s Hospital, Catholic Univeristy of Korea.

eprint requests: Jong-Hun Ji, MD, Department of OrthopaedicSurgery, Daejeon St Mary’s Hospital, Catholic University ofKorea, 520-2, Daehung-Dong, Daejeon, South Korea 301-723(E-mail: Junwoo0220@yahoo.co.kr).

Shoulder Elbow Surg 2007;16:e1-e5.opyright © 2007 by Journal of Shoulder and Elbow SurgeryBoard of Trustees.

058-2746/2007/$32.00

fioi:10.1016/j.jse.2006.09.013

Figure 3). The anconeus and flexor muscles were inter-osed in the elbow joint. Rupture of the medial and lateralollateral ligaments was also observed.

To remove the interposed structures impeding reductionrom both the medial and lateral sides, we made separateedial-side and lateral-side incisions on the elbow joint.fter the common extensor tendons were exposed laterally,

he radial head was not visualized (Figure 4, A). The tornnconeus muscle and torn radial collateral ligament wereaught between the radial head and the posteroinferiorrochlear-capitellar junction. The lateral joint was openedia a varus force, and the anconeus muscle was pulled outently. Subsequently, reduction was attempted by applica-

ion of a force distally and anterolaterally. The radial headas reduced, with some difficulty, and the remnant of thenconeus and lateral collateral ligament was relocated

aterally (Figure 4, B). The annular ligament remained in-act. The lateral collateral ligament was ruptured and sep-rated from the dorsal part of the lateral epicondyle. Theuptured anconeus and lateral collateral ligament wereepaired to the lateral epicondyle by use of a 5-mm metallicnchor loaded with double No. 2 sutures (Figure 4, C). Theuptured extensor tendons were firmly sutured to the lateralpicondyle via No. 2 Ethibond (Ethicon, Somerville, NJ).n the medial side, the ulnar nerve was traced and sepa-

ated carefully. We found a rupture of the posterior onehird of the flexor muscles (Figure 5, A). On MRI, theseuptured flexor muscles were noted to be interposed in theedial ulnotrochlear joint. They were retrieved and at-

ached to the medial epicondyle via a No. 2 Ethibondullout suture technique (Figure 5, B).

Plain radiographs obtained after surgery showed a per-ect reduction of the elbow joint (Figure 6). A posterior splintith the elbow joint in 90° of flexion was applied. After the

igure 1 Deformed elbow and small ecchymosis seen on postero-edial aspect of elbow.

rst week, the splint was removed during the daytime, and

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xercises that allowed range of motion of approximately0° to 90° were initiated. At 3 weeks, exercises with range

Figure 2 Initial anteroposterior (A) and lateral (Bdislocation of both radius and ulna with respect to hu

Figure 3 A, T2-weighted sagittal magnetic resonancecapitellum. Hypointense T2 signal lesion (red arrow) iscoronal (B) and axial (C) images show irregularly sharepresenting interposed anconeus muscle (B, red arroflexor muscles (yellow arrow). Rupture of the anconeu

f motion from 10° to approximately 120° were allowed. O

se of the night splint was discontinued 4 weeks afterurgery, and full range-of-motion exercises were started.

ple radiographs of elbow showing posteromedial.

ge showing posterior dislocation of radius relative toin the displaced radiocapitellar joint. The T2-weightedhypointense signal lesion in the radiocapitellar joint,and in the ulnotrochlear joint, suggesting interposedcle is also seen (C, red arrow).

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J Shoulder Elbow Surg Kim and Ji e3Volume 16, Number 6

f motion (Figure 7). Mild tingling on the medial aspect ofhe elbow joint had disappeared. He had no pain, a goodrc of motion, and no limitation in daily activities. At the lastollow-up, the Mayo Elbow Performance Score showed anxcellent result (100 points) and no instability. The Hospitalor Special Surgery score was 98 points, including a sub-core of 8 points for strength, at the last follow-up.

ISCUSSIONDislocation of the elbow joint is less common than the

islocation of the shoulder and finger joints. Posterior andosterolateral dislocations constitute 80% to 90% of elbowislocations, and dislocation of the radius and the ulnalone is very rare.6

Most cases of dislocation of the elbow are readily re-uced by simple traction. Common causes of irreduciblelbow dislocations include associated injuries such as avul-ion fractures of the medial epicondyle1 and, rarely, the

Figure 4 A, A photograph taken in the operative fimuscle mass was seen with a torn radial collateral ligaand the posteroinferior trochlear-capitellar junctionC, Repaired anconeus muscle and lateral collateral lig

Figure 5 Torn flexor muscle mass (arrow) above me(arrow) (B).

ateral epicondyle9 of the humerus. Such fractures impede t

eduction and are common in children. However, cases ofimple dislocation of the elbow joint without associatedractures that required open reduction have been rarelybserved. Linscheid and Wheeler7 reported that among10 cases with dislocation of the elbow, only 2 had dislo-ations necessitating open reduction. In simple dislocationsithout accompanying fractures, soft tissues act as the

tructure impeding reduction.Until recently, reported impediments to reduction were

he brachial muscle, the anconeus muscle, the biceps ten-on, and the collateral ligaments. Chhaparwal et al2 haveeported injury of the medial side of the elbow joint withrreducible dislocation of the elbow joint and a pronatedorearm, and they reported that the brachial muscle acteds a tight band and thus impeded reduction. Smith10 alsoeported that although the capitellum was avulsed, therachialis impeded reduction.

Exarchou4 reported on a case with lateral dislocation of

howed the posteromedial dislocation. The anconeus, and these were interposed between the radial headw). B, The annular ligament was intact (arrow).t (arrow) laterally.

epicondyle medially (A) and repaired flexor muscle

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e4 Kim and Ji J Shoulder Elbow SurgNovember/December 2007

Figure 6 Postoperative anteroposterior (A) and lateral (B) simple radiographs of elbow showing well-reduced

elbow joint.

Figure 7 A and B, Clinical follow-up photographs at 1 year postoperatively.

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ented by the stretched anconeus that was interposed be-ween the lateral humeral condyle and the ulna. In our case,he ruptured anconeus and lateral collateral ligament werenterposed between the radial head and the posteroinferiorrochleo-capitellar joint.

The lateral collateral ligament and capsule comprisenother obstacle, and 2 cases (1 adult patient5 and 1ediatric patient3) have been reported in which the radialead was prominent because it was caught in a buttonholeear of the lateral collateral ligament and capsule.awlowski et al8 reported on a posterolateral dislocation ofhe elbow that could not be reduced. The ulnar collateraligament and capsule were torn and caught between theadial head and the posteroinferior trochleo-capitellar joint.able I shows the reported obstructions in irreducible elbowislocation cases.

In our case, we tried to reduce the elbow joint twice butailed. Because of severe pain, an accurate physical exam-nation could not be performed. On plain radiographs, theefinite diagnosis of posteromedial dislocation could beade, and MRI identified the soft tissues involved (Figure). Previous reported cases have rarely commented accu-

able I Reports of irreducible elbow dislocation in English-anguage literature

Author YearDislocation

type Obstacles

mith10 1954 Lateral Brachialisinscheid and

Wheeler71965 Lateral Brachialis, anconeus,

collateral ligamentevadoss3 1967 Posterior Buttonhole tear in

posterolateral capsuleawlowski et al8 1970 Posterolateral Radial collateral ligamentxarchou4 1977 Lateral Anconeusreiss and Messias5 1987 Posterolateral Buttonhole tear in

posterolateral capsulehhaparwal et al2 1997 Lateral Brachialis

ately preoperatively on which structures were blocking

eduction and only described operative findings. Preoper-tively, on MRI, these tissues appeared to be muscles, asetected by moderate intensity on the T1-weighted imagesnd low intensity on the T2-weighted images. The findingsf the ruptured medial collateral and lateral collateral liga-ents were also noted. Most surgeons worry that operative

reatment may increase the risk of soft-tissue adherence andcar formation. In our case, early repair of the anconeusnd medial and lateral collateral ligaments, together witheduction of the dislocation, allowed early rehabilitation.

In the past, it has been difficult to obtain an accuratenderstanding of interposed structures in cases of irreduc-ble elbow dislocations preoperatively. However, thanks tohe high resolution of MRI, an accurate understanding oftructures impeding reduction can be achieved readily. Byerforming accurate preoperative planning, appropriateurgery, and early postoperative rehabilitation, a goodesult can be achieved.

EFERENCES

1. Bulut G, Erken HY, Tan E, Ofluoglu O, Yildiz M. Treatment ofmedial epicondyle fractures accompanying elbow disloca-tions in children [in Turkish]. Acta Orthop Traumatol Turc2005;39:334-40.

2. Chhaparwal M, Aroojis A, Divekar M, Kulkarni S, Vaidya SV.Irreducible lateral dislocation of the elbow. J Postgrad Med1997;43:19-20.

3. Devadoss A. Irreducible posterior dislocation of the elbow. BrMed J 1967;3:659.

4. Exarchou EJ. Lateral dislocation of the elbow. Acta Orthop Scand1977;48:161-3.

5. Greiss M, Messias R. Irreducible posterolateral elbow disloca-tion. Acta Orthop Scand 1987;58:421-2.

6. Josefsson PO, Nilsson BE. Incidence of elbow dislocation. ActaOrthop Scand 1986;57:538-9.

7. Linscheid RL, Wheeler DK. Elbow dislocations. JAMA 1965;194:1171-6.

8. Pawlowski RF, Palumbo FC, Callahan JJ. Irreducible posterolat-eral elbow dislocation. J Trauma 1970;10:260-6.

9. Pouliart N, De Boeck H. Posteromedial dislocation of the elbowwith associated intraarticular entrapment of the lateral epicon-dyle. J Orthop Trauma 2002;16:53-6.

0. Smith MF. Surgery of the elbow. Springfield (IL): Charles C.

Thomas; 1954. p. 233-4.