Posterior Elbow Dislocation in a

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• Posterior Elbow Dislocation in a
• Professional Football Player
• Jim Keller
• Assistant Athletic Trainer
• Denver Broncos

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Thanks to the Following Steve Antonopulos
A.T.,C Ted Schlegel MD Corey Oshikoya
A.T.,C Charlie Ho MD Kathy Paniello RN
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Case Study

• 34 yr old tight end/13th season
• Tackled posterior lateral force
• Hyperext/valgus mechanism
• R Elbow Subluxation/Dislocation?
• Spontaneous reduction
• Removed field/game
• X-Ray, compression/sling
• Rehab 11/12/03, post MRI
• R Elbow simple post. dislocation
• 11/27/03 Practice (16 Days)
• 12/08/03 Game (27 Days)

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• Unlike the shoulder, the elbow joint is
  inherently stable because of the anatomy of the
  articulation. Elbow dislocations are usually a
  high energy episode with severe soft tissue
  injury. Residual loss of motion is common but
  recurrent instability is rare.
  ODriscoll et al(1990)

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MRI Results

• Disruption of the anterior capsule with 2-3cm
  defect of distal brachialis with extensive
  hemorrhage and fluid.
• Tearing/stripping of the anterior bundle of the
  medial collateral ligament complex, distally
  greater than proximal
• High grade partial tearing of the common flexor
  tendon at medial epicondyle and hemorrhage within
  the flexor pronator musle mass.
• Large joint effusion with multiple internal
  bodies.

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Simple vs Complex Dislocations

• Complex Dislocation A more complex injury
  involving injury to both bones and ligaments in
  the joint. Usually resulting in instability of
  the joint and may require surgical intervention.
• Simple Dislocation A dislocation producing soft
  tissue damage to the surrounding joint. Most
  often instability is not an issue and therefore
  can be treated through rehabilitation.
• Hildebrand et al (1999)

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Mechanism of Injury

• Result of hyperextension most commonly from a
  fall. Anatomically the olecranon impinges in the
  olecranon fossa levering the trochlea over the
  coronoid process.
• Andrew et al(2002)
• Combination of axial compression, elbow flexion
  valgus stress and forearm supination creating a
  rotational displacement of the ulna on the
  humerus.
• ODriscoll et al(1992)

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Surgery vs Treatment

• There is clear consensus that the best results
  following a simple posterior dislocation are
  conservative treatment, with early aggressive
  movement and minimal immobilization. The
  rehabilitation protocol attempts to restore early
  range of motion, regain full function and
  decrease time loss.
• 1. Unstable elbows (require more than 60 degrees
  of flexion to stay reduced). The instability
  is most often due to a fracture
• 2. Competitive throwers (especially pitchers).
  High stressed placed on the medial elbow during
  cocking and acceleration phase of throwing.
• Andrews et al (2002)

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NFL Injury Analysis

• 64 Elbow Dislocations
• 22 NFL Seasons
• Average time loss is 38 days
• Median time loss is 30 days
• All 64 dislocations occurred during a game
• 1 case surgery was performed
• Powell (SIMS)

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3 Simple Posterior Dislocations

• Case 1 (2002) TE
• R Elbow dislocation
• Return to practice 16 days
• Return to game 27 days
• Case 2 (2000) WR
• L Elbow dislocation
• Return to practice 29 days
• Return to game 35 days
• Case 3 (2000) DB
• R Ebow dislocation
• Injured reserve 48 days
• Clav Fx, eye abrasion, R hamstring L gamekeeper,
  R bennetts fx

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Rehabilitation Protocol
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Cornerstones of Rehab Program

• Hinged Brace/Compression
• NSAIDS
• Ice and Elevation
• Early aggressive PROM avoiding unstable extension
  and pain
• Rehab is not a cookbook
• Communicate with athlete
• Soft tissue massage techniques
• Working entire kinetic chain
• Stabilization exercises
• Custom fit functional brace upon return

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Bracing

• Hinged Brace
• Set ROM limitations
• Allows for compression
• Able to sleep in brace
• Allows rehab to begin
• Long term Immobilization
• Unable to rehab early
• Adhesions, fibrosis, contractures
• Shortening anterior capsule
• Intra-articular adhesions and stiffness,
  decreasing ROM
• Melhoff et al (1987)

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• Passive ROM (2 Days)
• Active ROM (5 Days)
• Hydro therapy (6 Days)
• Stretching (5 Days)
• Early protected ROM promotes healing of the bone
  and articular cartilage, increases tensile
  strength of soft tissue and minimzes adhesion
  formation, that cause stiffness.
• Hunter et al(2002)

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• Efflurage (2 Days)
• Soft tissue massage (4 Days)
• Myofascial release (5 Days)
• ART (21 Days)
• MAT (16 Days)
• Techniques are used to decrease inflammation,
  increase mobilization, mechanically stretch the
  skin, fascia and muscle tissues to help restore
  normal joint motion and kinematics.
• Hunter et al(2002)

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• Sport cord Bicep/tricep wrist (10 Days)
• Sport cord Shoulder (12 Days)
• Manual resistance wrist, bicep/tricep (7 Days)
• Manual resistance shoulder (9 Days)
• PNF (Did not perform)
• Weight room bicep/tricep (12 Days)
• Weight room upper body modified (19 Days)

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• Closed chain seated (8 Days)
• Closed chain standing (9 Days)
• Closed chain quad/tripod (11 Days/15 Days)
• Closed chain uneven surface (14 Days)

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• Body blade (DNP)
• Ball stabilization (5 Days) for sit-ups/lower
  extremity
• SS stance (12 Days)
• SS running (12 Days)
• SS blocking (12 Days)
• SS catching (10 Days)

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Custom Fit Brace

• ROM limitations
• Custom fit to individual
• Provides stability
• Protects from trauma
• Compact size
• Increases confidence

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Transitional Rehabilitation

• Continue pain modalities
• Light A/P mobs
• Scale back amount of resistive exercises in TR
• Increase progression in weight room
• Keep on the field/happy medium
• Adapt bracing as needed
• Pad opposite elbow

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Conclusions from case study

• Complete and early diagnosis
• Compliant driven athlete
• Short immobilization with early rehab
• Accelerated rehab protocol
• Ability to adjust

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Thank You for your time!