FIGURE 6: Reduction by.pusher. Technif/IUs

IIIbow DioIoc:8IU8 ia CIIiIcha -- AIW8J8.Baip lajlay - Paae S FIGURE 5: RetblaiOll Forces FIGURE 6: Reduction by.pusher. Technif/IUs

2) Blbow DiIIoc:8Iic8IIa CIIitona - HalAI..,.. 8cIIiplajay - PIac 6 Pulling techniques simultaneous longitudinal pull applied along humerus and forearm patient either supine or prone (FIGURE 7] c FIGURE 7: Retbu:tiOll by -PIIller- Tecluliq8es b. Hankins lever mechanism (H8tiaI"84) 1) Uses the surgeon's forearm to lever the foreshortened forearm of the patient into the reduced position. (FIGURE 8]...---.-----,.'" FIGURE S: Htllltiu mnlwd uilll the fort!antiof the nugeolliu a lner jiilcnu1i to facilitate retbu:tioliof a dwdctitedelbow. (lleprodllcetlwitlape1'8wiollfrom Htllltill, Posterior Dislocation of the Elbow..if Simplified Method of Closed Reduction. HtI1Ilci",F.M., Cli,,- Dnlwp. 1990:254-256, 1984.)

"~ BIbow ~ ill 0iIdn:II -NotAIwaJo. Baoiplajllry- 7 E. c. Always check median nerve reduction!! function, pre and post 3. Immobilization a. Elbow flexed90" b. Forearm mid position c. Start active motionin sevento ten days. Treatment(AnteriorDislocation) [FIGURE 9] FIGURE 9: Retbu:tioll forces of liiiterior tlulocatioll. F. 1. Must dislodgeposteriorolecranonfrom anterior humerus. (Arrow 1) 2. Humerusdisplacedforward. (Arrow 2) 3. Forearm displaceposterior. (Arrow 3) 4. Immobilizein some extension. (Arrow 4) Complications 1. The most commoncomplicationis residualelbow stiffness. a. Usuallyonly 10"- 15 of loss of extension. b. Rarely of any cosmeticor functionalsignificance. 2. c. It is importantto warn parents before treatmentthat there may be some residual stiffness. Neurological Injuries a. Ulnar Nerve 1) Most common nerve injured.

BIllow~ IIICIIiIIh8 -Mat AIW8J8. BCIIip IIIJ8r7-8 b. 2) Most commonly associated with medial epicondylar fracture. Median nerve 1) Usually transient loss due to simple stretch (See Figure 4). 2) Entrapment can occur by one of three mechanisms: [FIGURE 10] n- -.-.----.------- Type 1 Type 3 FIGURE 10~. JledilJla Nerve E18trap1llt!1II 3. Type1 - Type2 - true entrapment within the joint entrapment between the surfaces of the medial epicondyle Type 3 - Simple kinking of nerve anteriorly 3) If the nerve bas been entrapped for a long time there is a posterior notching of the medial condyle (Matev Sign). [FIGURE 11] Arterial Injuries a. The brachial artery can be either: 1) Displaced and interposed within the joinfwiiadiunt, '89). 2) Completely disrupted.

BIllow DidacaIio8a ia DtiIdrca -Mat AIwaJ8. Baip I8jary - PIp 9 -- --- FlGUllE 11: 71Ie-Mlltn Sig,,- 4. 5. 6. b. Open elbow dislocations are the most common cause of brachial c. artery disruption. With most dislocations the collateral vascular systems are often d. disrupted. (See Figure 4) Thus, rupture of the main artery can lean to serious vascular e. compromise in elbow dislocations. Any sign of vascular compromise to the forearm needs aggressive treatment (i.e., immediate exploration and repair). Heterotopic ossification a. Quite commonin collateralligaments b. Rarely results in significantloss of motion. True myositis ossificans a. Fortunatelyrare b. Can be preventedor lessenedby avoiding: 1). Hyperextension 2) Vigorouspassivemotionduring rehabilitation RecUlTent dislocations. a. Pathologyinvolvesthree areas: [FIGURE 12] 1) Lax ulnar collateralligament 2) A lateralpocket in the radial collateralligament. 3) Defect in the lateralcondyle(failureof lateral ligament to reattach. b. Treatment involves repairing and reattaching the posterior lateral capsule and collateral ligament to the lateral condylar ridge. [FIGURE 13]

BIbow~ ia CIIiIdR8-Hal AIwaJ8. BC8ip lajuy - Pqc 10 lateral "pocket" ax ulnar collateral ligemant 1\ i I: FIGURE 12: Ptltllology 01 ~CII1Tent DialocatiolU ----- \i I( FIGlJIlR 11: Lateml Capmlar ltajtttu:iuriellt 7. 8. Unreduced dislocations a. If dislocation older than 5-7 days, open reduction is probably procedure of choice. b. A delayed elbow reduction probably gives better elbow function than leaving the elbow unreduced(~ '76). c. Avoid resection arthroplasty in the skeletally immature individual. Congenital Dislocations a. Can be confusedwith acute injury. b. Often bilateral, thus x-ray oppositeelbow.

BIllowDiIIoc8tioa8ia CIIiIdrao- Not AhrayIallc8ip lajuy - 11 III. ISOLATED RADIAL HEAD DISLOCATIONS A. Incidence 1. Rare and most commonly associated with occult fractures of the proximal ulna. B. 2. Most commonly anterior. Major diagnostic problem lies in differentiation from" congenital" dislocation of the radial head. 1. Congenital radial head dislocation demonstrates: a. short ulnar and long radius b. hypoplastic capitellum c. d. dome shaped radial head with long neck absence of a defined articular surface for the radius on the c. Treatment proximal ulna. 1. Up to three weekspost injury try closedreduction. 2. Up to threeyears mayperformopenreductionand reconstructionof the annular ligament using a strip of triceps (Bell-Tawseprocedure). [FIGURE 14] - - FIGVRE 14: Bell-Tawse Procedure. (Reproduced with permission from Bell- Tawse, A.J. S.: TIaeTreatment of Mal1uUtedAnterior MOfItt!glitJ Fractllres in Children. J. Bone Joint Surg., 47B:718-723, 1965.) a. Bell- Tawse(Bc11-Taw8 65)originally used a central slip of the triceps tendon. b. Lloyd-Roberts(Uo,d-RobertI 77) modified the procedure using the stronger lateral aspect of the triceps tendon. c. The radial head is temporarily stabilized while in the cast with transcapitular pin. d. Most of the elbow flexion and extension returns. Forearm pronation and supination may have some residual limitation of motion.

BIllow~ ia CIdIona - MatAI..,.. 8aip IajaJ - PIp 1%... """"""'" """""" """"""'"... """""""""""""""""""""... """""""""""""""",......,..... """",.....,..,..., """'" """'",,,,... """""""", """""""""'"......, "......--...-... ;;;.:~;;..: II'&1#tlflJi1a~i~'~:;:::':~:; :~::: ~:::::~::i!!#~:~.lj~(i4~:: C~~lii~:~: ::!r~:;:~wi~~~::.~p~~:~~~ i,-,g~::il~i1:~~:: :::::::: ~:~~/:~/r~(%:r~~jtp1tf~!l?fht~mh0,:({~rh/h:////:::./~hh-.: References RecurrentDislocation of the Elbow. Doria, A.; Gil, E.; Delgado, E. and Alonso-Uames, M.: Internat.Orthop., 14:41-45, 1990. A more recent article describing the management of recurrent dislocations of the elbow. Confmns the need to repair the posterolateral capsule to obtain a good result. BrachialArtery Disruptionin Closed Elbow Dislocation. Wilmhurst,A.D.; Millner, P.A. and Batchelor, A.G. Injury,20:240-241, 1989. A case of displacement with obstruction of an intact brachial artery in a closed elbow dislocation without fracture. PosteriorDislocation of the Elbow. A SimplifiedMethodof Closed Reduction. Hankin, F. M., Clin. Orthop. 1990:254-256, 1984. Describes a new technique of reducing elbow dislocations in which the surgeons forearmis used as a lever system to facilitate the reduction. Entrapmentof the Median nerve after Dislocation of the Elbow. Hallett, J. J. Bone Joint Surg., 63B:408-412, 1981. Describesin detailthe pathologicalfindingsof an entrappedmediannerveafter reductionof a dislocatedelbow. Defines threetypes of entrapmentpatterns. CongenitalRadialHead Dislocation. Mardam-Bey,T., and Ger, E. J. HandSurg., 4:316-320, 1979. Describesthe differentialfeaturesof a congenitaldislocationof the radialhead which enablesthe physicianto differentiateit from an acutedislocation of the radialhead. Anterior Dislocation of the Radial Head in Children. Lloyd-Roberts,G.C. and Bucknill, T.M. J. Bone Joint Surg., 59B:402-407, 1977.

BIbow DiIIoc:8IiI8 Ia CIIiIch8 - NutAI..,.. Baip lajuy - Pale 13 Delineates the results of open reduction of eight cases of acute and delayed dislocation of the radial head. Most were unrecognized Monteggia lesions. Recommends a modification of the Bell-Tawse procedure. Treatment of Old Unreduced Dislocation of the Elbow. Wong, K.P. Injury., 8:39-42, 1976. Krishnamoorthy, S.; Bose, K and One of the best articles on the management of old reduced elbow dislocations. Felt late surgical reductions produced better results than leaving them unreduced.. A radiological Sign of Entrapment of the Median Nerve in the Elbow after Posterior Dislocation. Matev, I. J. Bone Joint Surg., 58B:353-355, 1976. Describes a grooving in the posterior medial aspect of the distal humerus from pressure on the bone by the entrapped median nerve. Arterial Injury: A Complication of Posterior Elbow Dislocation. Louis, Dean S.; Ricciordi, J.E. and Spengler, D.M. J. Bone Joint Surg., SGA: 1631-1636, 1974. Demonstrated the anatomical basis of why the collateral circulation is compromised when the brachial artery is ruptured secondary to an elbow dislocation. Emphasizes the need for primary repair of the artery. Recurrent Dislocation of the Elbow. Osborn, G. and Cotterill, P.J. Bone Joint Surg., 48B:340-346, 1966. Describes the pathological defect as being a failure of reattachment of the posterior lateral aspect of the capsule to the lateral condyle. Delineates a soft tissue repair technique. The Treatment of Malunited Anterior Malunited Anterior Monteggia Fracture in Children. Bell-Tawse, A.J.S. J. Bone Joint Surg., 478:718-723, 1965. An article delineating the indications and techniques of correcting residual deformities from Type I Monteggia Lesions and operative correction of traumatic dislocation of the radial head.