Atraumatic elbow dislocation without fractures in an elderly patient

Introduction: Atraumatic dislocation without fractures is a very rare condition in elderly patient. Elbow dislocations are frequently affiliated with a variety of fractures involving the ulna and radius. To our knowledge, there is not any record of adult atraumatic elbow dislocation without fractures in literature. Case Report: Herein, we report a case of a purely left elbow dislocation in an elderly patient without obvious trauma. Good reduction was achieved by closed method. We present a review of literature highlighting the characteristics and treatment options of this rare condition. Conclusion: The good understanding of the pathophysiology of this type of dislocation helps to avoid during the reduction maneuver; any fracture or incarceration of ulnar nerve, requiring the surgical reduction and worsening the functional prognosis of the elbow. (This page in not part of the published article.) International Journal of Case Reports and Images, Vol. 5 No. 8, August 2014. ISSN – [0976-3198] Int J Case Rep Images 2014;5(8):595–599. www.ijcasereportsandimages.com Bassir et al. 595 CASE REPORT OPEN ACCESS Atraumatic elbow dislocation without fractures in an elderly patient Rida-Allah Bassir, Monsef Boufettal, Mustapha Mahfoud, Ahmed Elbardouni, Mohamed Saleh Berrada, Moradh Elyaacoubi


IntroductIon
Purely dislocation of the elbow is a rare condition especially in elderly patient without obvious history of trauma [1]. Elbow dislocations are frequently affiliated with a variety of fractures involving the ulna and radius [2]. To our knowledge, in literature there is not any record of adult atraumatic elbow dislocation without fractures. We present the observation with a good outcome after a reduction by closed method, and the review of literature highlighting the characteristics and treatment options.

cAsE rEPort
A 63-year-old female arrived in the emergency department without history of acute injury. The patient had one-year history of rapidly progressing, rheumatoid arthritis involving her hands, elbows, and shoulders. RA-latex reaction was positive, rheumatoid factor concentration was 360 IU/mL, and C-reactive protein was constantly high (80 +/-20 mg/L). The clinical examination revealed a valgus deformity of the left elbow without neurovascular deficit (Figure 1). Identified injuries in radiographs included: a posterolateral dislocation of the left elbow without fracture (Figures 2 and 3). No other injuries were diagnosed. The patient was taken to the operating room, placed in the supine position and general endotracheal anesthesia was administered. A reduction by closed method with soft traction in supination of the forearm and pushing the olecranon medially was made. www.ijcasereportsandimages.com

Bassir et al. 596
The control in image intensification was satisfactory ( Figure 4). With, as expected, a reduction was unstable to valgus stress ( Figure 5), but remained stable through an arc of flexion and extension. Then the patient was placed in a posterior splint. At sixth month follow-up, the elbow was stable and painless with full mobility.     dIscussIon Elbow dislocations are a usually high-energy traumatic event resulting in the loss of congruence of a stable joint. Purely, atraumatic elbow dislocations have never been reported in adult patient. Only one case of bilateral atraumatic dislocation of the shoulder has been reported in literature [1].
Rheumatoid arthritis is a common chronic inflammatory disorder. The shoulder joints are involved in the majority of patients with rheumatoid arthritis (50-70%) [3]. Newell in his series of 1114 elbow injuries do not found a similar case [4]. These dislocations are normally reduced by distal traction on the forearm with the elbow held in mild extension and then straight lateral pressure [5]. To our knowledge, such injuries have not been previously reported in old age [6]. This type of dislocation is only possible by important capsulolabral damage interesting three bundles of the medial collateral ligament. This medial capsulolabral damage release the ulnar nerve of all his fasteners. So that, it takes it to an oblique way, and protects it of a possible rupture or elongation. It exposes it more to risk of incarceration, especially, when we try a reduction. Chhaparwal et al. reported the cause of irreducibility to brachialis muscle and the ulnar nerve incarceration [7]. The neurovascular injuries secondary to this type of dislocation are even more outstanding, only one case of radial nerve palsy was reported by Koulali et al.
[8] and a case of injury to the radial artery reported by Cumming et al. [9].
Posterolateral dislocation of the elbow joint can lead to persistent valgus instability that is associated with a worse overall clinical and radiographic result [6]. The reduction of this type of dislocation is reputed to be difficult because of the high risk of fractures and incarceration. In our case, the reduction by external maneuver was not pose a problem. According to Khan et al., reduction requires two persons [10]. The first one maintaining upper limb in extension and supination, and the second one guide the olecranon medially by a soft push, which should achieve a reduction of the dislocation. In the event of irreducibility after the attempt, the surgical approach is necessary to seek for a possible incarceration. The elbow is reputed to be the joint having the most frequent stiffness complication, posing the problem of post reductional immobilization. The cases reported has no problem of stiffness after three weeks of cast immobilization.

concLusIon
Through this observation of a purely atraumatic dislocation of the elbow, we draw attention to the rarity of this entity, especially on the necessity of a good clinical and radiological analysis. Moreover, the good understanding of the pathophysiology of this type of dislocation helps to avoid during the reduction maneuver; any fracture or incarceration of ulnar nerve, requiring the surgical reduction and worsening the functional prognosis of the elbow.

Edorium Journals: An introduction
Edorium Journals Team

But why should you publish with Edorium Journals?
In less than 10 words -we give you what no one does.

Vision of being the best
We have the vision of making our journals the best and the most authoritative journals in their respective specialties. We are working towards this goal every day of every week of every month of every year.

Exceptional services
We care for you, your work and your time. Our efficient, personalized and courteous services are a testimony to this.

Editorial Review
All manuscripts submitted to Edorium Journals undergo pre-processing review, first editorial review, peer review, second editorial review and finally third editorial review.

Peer Review
All manuscripts submitted to Edorium Journals undergo anonymous, double-blind, external peer review.

Early View version
Early View version of your manuscript will be published in the journal within 72 hours of final acceptance.

Manuscript status
From submission to publication of your article you will get regular updates (minimum six times) about status of your manuscripts directly in your email.

Mentored Review Articles (MRA)
Our academic program "Mentored Review Article" (MRA) gives you a unique opportunity to publish papers under mentorship of international faculty. These articles are published free of charges.

Most Favored Author program
Join this program and publish any number of articles free of charge for one to five years.

Favored Author program
One email is all it takes to become our favored author. You will not only get fee waivers but also get information and insights about scholarly publishing.

Institutional Membership program
Join our Institutional Memberships program and help scholars from your institute make their research accessible to all and save thousands of dollars in fees make their research accessible to all.

Our presence
We have some of the best designed publication formats. Our websites are very user friendly and enable you to do your work very easily with no hassle.
We request you to have a look at our website to know more about us and our services.
We welcome you to interact with us, share with us, join us and of course publish with us.

Invitation for article submission
We sincerely invite you to submit your valuable research for publication to Edorium Journals.

Six weeks
You will get first decision on your manuscript within six weeks (42 days) of submission. If we fail to honor this by even one day, we will publish your manuscript free of charge.

Four weeks
After we receive page proofs, your manuscript will be published in the journal within four weeks (31 days). If we fail to honor this by even one day, we will publish your manuscript free of charge and refund you the full article publication charges you paid for your manuscript.