Dislocations of the elbow in children

M. N. Rasool
From the Nelson R.
Mandela School of
Medicine, Congella,
South Africa
A total of 33 children were treated for acute traumatic dislocation of the elbow between
1994 and 2002; 30 dislocations were posterior and three anterior. Eight children had a pure
dislocation and 25 had an associated fracture of the elbow. Two had compound injuries.
Two children had injury to the ulnar nerve, one to the radial nerve and one to the median
nerve together with injury to the brachial artery. Twenty required open reduction.
Complications included pseudarthrosis of the medial epicondyle in one child and loss of
flexion and rotation of between 10˚ and 30˚ in ten others. Meticulous clinical and
radiological assessment is mandatory in children with dislocation of the elbow to exclude
associated injuries.
The results were excellent to good in 22 patients, fair in ten and poor in one.

M. N. Rasool, FCS (Ortho)
(SA), Consultant Paediatric
Orthopaedic Surgeon
Department of Orthopaedic
Surgery, Nelson R. Mandela
School of Medicine, Private
Bag 7, Congella 4013,
Republic of South Africa.
©2004 British Editorial
Society of Bone and
Joint Surgery
doi:10.1302/0301-620X.86B7.
14505 $2.00
J Bone Joint Surg [Br]
2004;86-B:1050-8.
Received 23 April 2003;
Accepted after revision
3 October 2003
Traumatic dislocation of the elbow is rare in
children with an incidence of only 3% to 6%1
of all elbow injuries and there has been only
one study describing this injury exclusively in
children.2 The most recent publications have
been case reports of rare forms of dislocation
and associated complications.3-16
Dislocations may be classified according to
the position of the proximal radio-ulnar joint
in relation to the distal humerus. Displacement
of the proximal forearm can occur in four
directions, either posterior, anterior, medial or
lateral.1
Pure dislocation is uncommon and radio-
graphs must be evaluated carefully for associ-
ated avulsions and fractures around the elbow.
Avulsion of the medial epicondyle is the most
common associated injury.1,17-21 Less common
are injuries in the region of the coronoid proc-
ess, radial head, olecranon, trochlea and lateral
condyle,1 or very rarely, there may also be dis-
ruption of the proximal radio-ulnar joint
(divergent type).3-10
The aim of this paper is to highlight the
spectrum of dislocations of the elbow and to
increase the awareness of the less common
types seen in children. The importance of
careful clinical and radiological assessment is
emphasised.
Patients and Methods
The clinical records and radiographs of 33
children with acute traumatic dislocation of
the elbow treated between 1994 and 2002 at a
major referral centre were reviewed retrospec-
tively. All children with displaced injuries
involving the elbow are routinely admitted and
reviewed by the consultant after initial assess-
ment and treatment by orthopaedic trainees.
Twenty-one children had been referred from
rural hospitals. All had standard anteroposte-
rior (AP) and lateral radiographs and in 23
radiographs were taken of the opposite elbow
for comparative views. There were 24 boys
and nine girls with a mean age of nine years (5
to 13). Every injury had been caused by a fall
and was seen and treated within five days. Two
children had compound injuries. Two had an
associated injury of the ulnar nerve, one of the
radial nerve and one of the median nerve with
disruption of the brachial artery. Radio-
logically, 22 of the dislocations were postero-
lateral, seven posteromedial, one posterior,
two anteromedial, and one anterolateral.
Associated fractures of the elbow were seen
in 25 children. In 18, the dislocation was asso-
ciated with a single fracture or avulsion and in
the remaining seven there were various combi-
nations. The fracture was not recognised on
the initial radiograph in eight children after ini-
tial reduction.
The various types of injury were grouped as
follows:
Pure dislocation (eight cases). Seven children had
a closed reduction. One (Fig. 1) had a com-
pound injury with severe soft-tissue disruption
and damage to the median nerve and brachial
artery. The latter was reconstructed using a

1050 THE JOURNAL OF BONE AND JOINT SURGERY

 DISLOCATIONS OF THE ELBOW IN CHILDREN 1051

reverse saphenous graft. The artery was subsequently

Fig. 1
Anteroposterior and lateral radiographs of the elbow showing a postero-
lateral dislocation. There is air in the tissues, extensive soft-tissue swell-
ing and disruption. The patient had injury to the median nerve and
brachial artery.
ligated because of failure of the graft. There was adequate
collateral circulation.
Dislocation with avulsion of the medial epicondyle (11 cas-
es). Ten dislocations were posterolateral (Fig. 2); one was
anteromedial. Seven children had a closed reduction. The
medial epicondyle was trapped within the joint in two chil-
dren who required open reduction and fixation with Kir-
schner wires (K-wire). In one of these the dislocation was
compound with associated injury to the ulnar nerve. Two
children with displacement of the medial epicondyle after
closed reduction required open reduction and fixation with
K-wires.
Dislocation with fracture of the lateral condyle (5 cases).
Four fractures were Milch type II (Salter-Harris type II) and
one, type I (Salter-Harris type IV). The dislocations were
posteromedial in four and anteromedial in one. All under-
went internal fixation with K-wires.
Dislocation with fracture and avulsion of the olecranon (one
case). This injury was associated with anterolateral disloca-

Fig. 2a

Fig. 2b

Radiographs showing a) posterolateral dislocation of the elbow and avulsion of the medial
epicondyle (arrows) and b) asymptomatic nonunion of the medial epicondyle at follow-up at
four years.

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1052 M. N. RASOOL

Fig. 3a

Fig. 3b

Figure 3a – Radiographs showing avulsion of the olecranon and anterior dislocation of the
elbow. The olecranon fragment is superimposed on the distal humerus. Figure 3b – Dia-
grams showing the avulsed olecranon (dotted lines).

tion (Fig. 3) and was treated by open reduction and fixation
with a single K-wire.
Posterior dislocation with fracture of the radial head. One
child had a posterior dislocation with an associated Salter-
Harris type I complete epiphyseal separation and was
treated by open reduction and K-wire fixation (Fig. 4).
Combined injuries (7 cases). In seven children the disloca-
tion was associated with more complex injuries of the
elbow. Three with posteromedial dislocations had the fol-
lowing injuries: 1) fracture of the lateral condyle (Milch II)
and avulsion of the medial epicondyle (Fig. 5); 2) avulsion
of the radial head (Salter-Harris type II) and olecranon apo-
physis; and 3) avulsion of the olecranon and medial epi-
condyle and injury to the radial head (Salter-Harris type II).
Two children with posterolateral dislocations had the
following injuries in combination: 1) avulsion of the ole-
cranon and medial epicondyle and injury to the ulnar nerve;
and 2) injury to the radial head (Salter-Harris type II) and
avulsion of the medial epicondyle.
All the injuries were treated by open reduction and K-
wire fixation.
Divergent dislocations. Two children with posterolateral
displacement of the elbow had a transverse type of diver-
gent dislocation of the proximal radius and ulna (Fig. 6). In
one reduction was achieved by traction and compression of
the radial head and olecranon, the other required open
reduction. The latter child also had signs of injury to the
radial nerve and, at surgery, the radial head was found to
have buttonholed through the lateral capsule and the origin
of the extensor muscles. The coronoid was avulsed and was
not visible on radiographs. The annular ligament was
repaired after reduction.
Fractures at other sites. Two children had a fracture of the
distal radius.
Delayed diagnosis. The diagnosis was delayed in eight chil-
dren. The associated fractures or avulsions had been over-
looked. Four required surgery to fix a displaced medial or
lateral condyle. Comparative radiographs showed overlap
of the fragments on bone in four. All dislocations which had
been reduced by closed manipulation were immobilised in a
collar and cuff sling for three weeks. Those with combined
injuries or who required surgery, were immobilised in a

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 DISLOCATIONS OF THE ELBOW IN CHILDREN
plaster backslab for four weeks. All had physiotherapy for
two to three weeks.
Results
The patients were reviewed at a mean of 10 months (4 to
48). The results were graded using the criteria of Roberts20
as follows: excellent, no symptoms, no limitation of move-
VOL. 86-B, No. 7, SEPTEMBER 2004
1053
Fig. 4a
Fig. 4b
Figure 4a – Radiographs showing posteromedial
dislocation of the elbow with a fracture of the lat-
eral mass and avulsion of the medial epicondyle.
The lateral mass is superimposed on bone on both
views. Figure 4b – Diagrams showing the avulsed
medial epicondyle and lateral mass (dotted lines).
Figure 4c – Radiographs showing reduction of the
medial epicondyle and lateral mass and fixation
with K-wires.
Fig. 4c
ment; good, mild symptoms, not >10˚ of loss of movement;
fair, moderate symptoms and 10˚ to 30˚ loss of movement;
and poor, severe symptoms, >30˚ loss of movement. There
were 22 children (67%) with excellent or good results, ten
fair and one poor result (Table I). Seventeen patients (52%)
had a full range of movement, and seven of these had a pure
dislocation.
1054 M. N. RASOOL

Fig. 5a

Fig. 5b

Fig. 5c

Figure 5a – Radiographs showing dislocation of the elbow and associated Salter-Harris

type I injury of the radial head. Figure 5b – Diagrams showing fracture of the radial head
(dotted lines). Figure 5c – Radiographs six months later showing healing.

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 DISLOCATIONS OF THE ELBOW IN CHILDREN 1055

Fig. 6a

Fig. 6b

Figure 6a – Radiographs showing divergent dislocation (transverse type) of the proximal

radio-ulnar joint on the AP views (arrows) and posterior dislocation of the trochlea ulnar
articulation on the lateral views. Cartilaginous avulsion of the coronoid is not visible. Fig-
ure 6b – Radiographs four months later showing good reduction. There is formation of new
bone anteriorly on the proximal ulna indicating healing of the coronoid.

Patients with closed reduction had a better outcome than
those requiring open reduction. The children with injury to
the ulnar and radial nerves recovered in two to four weeks.
Loss of movement was greater with injury to the lateral
compartment (radial head, and lateral condyle) than to the
medial compartment (medial epicondyle, olecranon and
coronoid). Combined and compound injuries resulted in a
greater loss of movement than isolated fractures. Asympto-
matic pseudarthrosis of the medial epicondyle was seen on
follow-up radiographs of one patient, four years after the
initial injury (Fig. 2b).
At follow-up at four months, the child with the vascular
injury had a fixed flexion deformity of 30˚ at the elbow and
rotational loss of 30˚, but there was a good collateral circu-
lation and no signs of ischaemia. The median nerve did not
recover.
Discussion
Carlioz and Abols2 reported the only large series of dislo-
cations of the elbow in children and found that 64% of
children had associated fractures and avulsions. Other
series included adults and children in their study17-20
(Table I).
In this study, 75% of the dislocations had an associated
injury to the elbow. In 24% of cases, an accurate diagnosis
was not made on the initial radiographs.
In all other studies the commonest associated injury was
avulsion of the medial epicondyle by the origin of the flexor
muscles and medial collateral ligament (Table II). The inci-
dence ranged from 25% to 36%2,22 and was similar to that
of this study (33%). The epicondyle is small and when dis-
placed it is difficult to see on routine radiographs; it may be
overlapped by the distal humeral metaphysis or confused
with the ossification centre of the trochlea or olecranon
(Fig. 2a). The management is controversial. Some authors
have advocated open reduction and internal fixation in all
cases to prevent instability and nonunion.23 Others have
considered surgery for the entrapped or displaced epi-
condyle to restore stability to the elbow.2,20,21 Recurrent
dislocations have been reported in adults who had injury to
the medial epicondyle in childhood17 but asymptomatic
fibrous union of the medial epicondyle has been seen in this
series and others.21,22
When avulsion of the olecranon is associated with dislo-
cation, the displacement is usually anterior1 as was
observed in this study. Osteochondral fragments from the

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1056 M. N. RASOOL

Table I. Literature review of dislocations of the elbow in children

Length of
Author/s review (yrs) Number of cases and age Type of dislocation Associated fractures Complications
Carlioz and Abols2 5 58 (<15 yrs) Posterior (all) Medial epicondyle 24 Pulse deficit 4
Pure 21 Olecranon 1 Ulnar nerve 2
Radial head, neck 3 Osteochondral flap (ulna) 2
Lateral flakes of bone 5 Radioulnar synostosis 2
Coronoid 2
Combined 2

Roberts20 11 24 (<14 yrs) Posterolateral 23 Medial epicondyle 8 Ulnar nerve 1

+36 adults Lateral 1 Lateral condyle 1 Median nerve 1
Pure 12 Radial head neck 2
Coronoid 1
Linscheid and Wheeler17 15 12 (<10 yrs) Details of injuries in
27 (11 to 20 yrs) children unknown
+71 adults
Josefsson and Nilsson18 12 13 (<20 yrs) Details of injuries in
+165 adults children unknown
Neviaser and Wickstrom19 10 31 (<10 yrs) Details of injuries in
39 (11 to 20 yrs) children unknown
+45 adults
Present study 8 33 (<13 yrs) Posterolateral 22 Medial epicondyle 11 Median nerve 1
Posteromedial 7 Lateral condyle 5 Radial nerve 1
Posterior 1 Olecranon 1 Ulnar nerve 2
Anteromedial 2 Radial neck 1 Brachial artery injury 1
Anterolateral 1 Coronoid 1
Pure 8 Combined 7 (Divergent 2)

Table II. Incidence (%) of associated fractures and injuries with osteochondral fractures of the trochlea.12,13 Grantham and
dislocations Tietjen14 reported an unusual transcondylar fracture-dislo-
Associated injury Carlioz and Abols2 Roberts20 Present study cation in which the fracture line was intracapsular and both
Medial epicondyle 36.0 33 33 distal humeral condyles were displaced as a single unit with
Lateral condyle 0.0 4 17 the elbow dislocated (Chutro-Posadas fracture).
Olecranon 1.7 0 3
Fracture of the lateral condyle occurring with dislocation
Radial head, neck 5.0 8 3
Coronoid 3.5 4 3 is very rare. Four cases have been reported by Newman25
Divergent 0.0 0 6 and one by Roberts.20 There was a higher incidence of iso-
Combined 3.5 0 20 lated fracture of the lateral condyle in this study compared
with others (Table II) and most dislocations were postero-
medial.
articular surface of the olecranon have been observed occa- Injury to the head and neck of the radius associated with
sionally to prevent reduction2 and such lesions may be dislocations of the elbow can occur during the process of
unrecognised on plain radiographs but found on explora- reduction when the capitellum can damage the distal lip of
tion. Carlioz and Abols2 emphasised that these lesions can the radial head. Alternatively, the radial neck may be frac-
cause recurrent dislocation of the elbow and that explora- tured during the process of dislocation when the capitellum
tion is indicated when inadequate reduction is seen on radi- can damage the proximal lip of the radial head.1,26 Three
ographs. such injuries were seen in this series all occurring during
Fracture of the coronoid is rare (<1%) and usually occurs dislocation. Steinberg et al26 reviewed the literature and
with dislocation in older children.1An unusual flap injury found 25 children with fracture of the head and neck of the
has been described in dislocations in which the articular radius with associated dislocation of the elbow. Some limi-
surface may be flipped back into the joint and prevent con- tation of rotation usually occurs after these injuries.
gruous reduction.15 Grant and Miller13 stated that unrecog- In our study most of the dislocations were posterolateral
nised osteochondral fragments may cause a poor result in (66%). The incidence of anterior dislocation is generally
an initially apparently uncomplicated dislocation of the low (< 2%).2,17-20 It may occur from a direct blow to the
elbow. If there is an indication for operative intervention, posterior aspect of the elbow,1 with avulsion of the inser-
the joint should be thoroughly inspected. In well-reduced tion of the triceps from the olecranon. The radius and ulna
dislocations there is no need to replace the coronoid avul- usually dislocate anteromedially.
sion surgically.1 Simultaneous dislocation of both the elbow and the
Dislocations with unusual associated fractures of the proximal radio-ulnar joint, includes disruption of all three
elbow have been reported. Fracture of the medial condyle joints of the elbow - the radiocapitellar, ulnotrochlear and
has been reported by Badelon et al24 and Saraf and Tuli.16 proximal radio-ulnar joints. The transverse type has been
Dislocations have also been observed in association with reported by other authors.3-11 The suspected mechanism of

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 DISLOCATIONS OF THE ELBOW IN CHILDREN
injury is thought to be a combination of axial loading on
the ulna and a strong pronation force causing disruption to
the proximal radio-ulnar joint, the interosseus membrane
and the annular ligament. Reduction is achieved by gentle
traction and compression of the radial head and ole-
cranon.5,9 Avulsion of the coronoid process has been
reported with this injury6,10 and was seen in this study. The
anteroposterior type of divergent dislocation seen in adults
has not been reported in children.1 Proximal radio-ulnar
translocation (convergent dislocation) has been described
in which the radius articulates with the trochlea and the
ulna with the capitellum as the forearm is clinically pro-
nated.3,4,11
Delay in diagnosis occurred in eight children because of
lack of interpretation of the radiographs. Most injuries
were fractures of the medial epicondyle or lateral condyle.
However, no serious morbidity occurred since these injuries
were recognised and treated before discharge. Complica-
tions reported after dislocations of the elbow have included
neurovascular injuries, loss of movement, myositis ossifi-
cans, radio-ulnar synostosis and recurrent dislocation. Inju-
ries to nerves are not uncommon after dislocation of the
elbow. The ulnar nerve is more frequently affected in dislo-
cations with avulsion of the medial epicondyle.21 These
injuries are usually transient and resolve completely.
Although Linscheid and Wheeler17 suggested that anterior
transposition of the ulnar nerve be performed at the time of
open reduction, others found that it was not usually neces-
sary except when signs of nerve compression were
present.2,20,21 The median nerve seems to be at greatest risk
in dislocations. The nerve has been found to be trapped
behind the medial epicondyle or within the joint after
reduction.27-34 Severe pain persisting after reduction of the
dislocation should alert the surgeon to entrapment of the
median nerve.29 Injury to the radial nerve after dislocation
has not been described in the literature. One child was seen
in this series with this injury after a divergent dislocation.
Vascular injury after dislocation of the elbow is unusual
but well-recognised. It is usually associated with open
dislocation35 or with an associated fracture.36,37 The vessel
may be contused, or suffer an intimal tear, thrombosis or
frank disruption.17 Rarely is the vessel injured by closed
dislocation.37 Very rarely is reconstruction performed since
there is usually an adequate collateral circulation.35,36 In
one study the absent pulse reappeared after reduction in
four patients. Myositis ossificans and heterotrophic ossifi-
cation have been reported, mainly in adults17,19,20 and
attributed to delay in treatment and vigorous early active
physiotherapy. Proximal radio-ulnar synostosis has been
noted to occur with an associated fracture of the radial
head.1
No case of recurrent dislocation was seen. It is rare in
children and is due to a failure of the capsule and ligamen-
tous structures to become reattached after traumatic dislo-
cation.17,23 The stability of capsular structures can be
assessed in the course of gentle post-reduction manipula-
VOL. 86-B, No. 7, SEPTEMBER 2004
1057
tion. A dislocation of the elbow in a child may be associated
with an unrecognised additional fracture. There should be a
high index of suspicion, with good clinical examination and
meticulous assessment of the radiographs and systematic
examination of the medial (medial epicondyle, olecranon,
coronoid, medial condyle) and lateral compartments
(radial head, lateral condyle) for associated fractures or
avulsions. Comparative radiographs are helpful for detect-
ing an overlap of fragments. MRI may reveal cartilaginous
fragments. Dislocations in children should ideally be
reduced under general anaesthesia and radiological control
to avoid delay in accurate diagnosis.
No benefits in any form have been received or will be received from any com-
mercial party related directly or indirectly to the subject of this article.
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