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Posterior Elbow Dislocation in a

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Title: Posterior Elbow Dislocation in a


1
  • Posterior Elbow Dislocation in a
  • Professional Football Player
  • Jim Keller
  • Assistant Athletic Trainer
  • Denver Broncos

2
Thanks to the Following Steve Antonopulos
A.T.,C Ted Schlegel MD Corey Oshikoya
A.T.,C Charlie Ho MD Kathy Paniello RN
84
3
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)

4
  • 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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9
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)

13
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)

14
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)

15
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)

16
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

17
Rehabilitation Protocol
18
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

19
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)

20
  • 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)

21
  • 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)

22
  • 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)

23
  • Closed chain seated (8 Days)
  • Closed chain standing (9 Days)
  • Closed chain quad/tripod (11 Days/15 Days)
  • Closed chain uneven surface (14 Days)

24
  • 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)

25
Custom Fit Brace
  • ROM limitations
  • Custom fit to individual
  • Provides stability
  • Protects from trauma
  • Compact size
  • Increases confidence

26
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

27
Conclusions from case study
  • Complete and early diagnosis
  • Compliant driven athlete
  • Short immobilization with early rehab
  • Accelerated rehab protocol
  • Ability to adjust

28
Thank You for your time!
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