OSCE Orthopedics: Reduction of Posterior Elbow Dislocation and Elbow Dislocation Slab and Advice about Elbow Dislocation Slab

Diagnosis of Posterior Elbow Dislocation

1. Clinical Assessment:
   • Patient Presentation: Look for pain, swelling, deformity, and inability to move the elbow.
   • Inspection: Check for visible deformity and assess skin integrity, noting any open injuries.
   • Palpation: Assess for tenderness around the elbow and check for signs of compartment syndrome.
   • Neurovascular Examination: Ensure distal neurovascular integrity by assessing the radial pulse and checking motor and sensory function in the radial, median, and ulnar nerve distributions.
2. Imaging: the image that we saw in the test is from https://www.orthobullets.com/trauma/1018/elbow-dislocation
   • Plain Radiographs:
     • AP and Lateral Views: Confirm the diagnosis by identifying the displacement of the olecranon posteriorly relative to the humerus.
     • Oblique Views: Use oblique views if there is suspicion of associated fractures or if additional detail is needed.
   • CT Scan (if needed): Perform a CT scan if you suspect a complex injury pattern, such as fractures of the radial head or coronoid, to assist in surgical planning if necessary.

Reduction of Posterior Elbow Dislocation: Step-by-Step

1. Preparation

• Analgesia and Sedation: Ensure the patient is adequately sedated and analgesic measures are in place to allow for muscle relaxation, which is essential for a successful reduction.
• Positioning: Place the patient supine on the table with the affected arm slightly abducted, supported, and the elbow flexed at about 45° to start.

2. Reduction Technique

Step 1: Inline Traction

• Grasp the Wrist and Forearm: Hold the patient’s wrist and forearm with both hands.
• Apply Traction: Use gentle, sustained inline traction on the forearm to counteract muscle spasm and help disengage the coronoid process from the trochlea.
• Improve Coronal Displacement: Continue traction to achieve coronal alignment, stabilizing the humerus with an assistant if possible.

Step 2: Forearm Supination

• Supinate the Forearm: Gradually supinate the forearm. This movement helps to shift the coronoid process of the ulna under the trochlea, moving the elbow into the correct anatomical position.
• Maintain Traction: Continue to apply gentle traction to keep the elbow steady and reduce spasm.

Step 3: Elbow Flexion with Pressure on Olecranon

• Flex the Elbow: While maintaining traction, slowly increase elbow flexion.
• Direct Pressure on Olecranon: Apply gentle, steady pressure on the tip of the olecranon to guide it back into its normal position. This maneuver should bring the ulna and humerus back into congruency.
• Feel for “Clunk”: A successful reduction often produces an audible or palpable "clunk" as the joint relocates.

3. Post-Reduction Assessment

• Stability Check: After reduction, assess for stability in different positions:
  • Extension Stability: Gradually extend the elbow to ensure it remains stable.
  • Valgus and Varus Stress: Apply stress tests in slight flexion to check for ligamentous stability.
• Neurovascular Reassessment: Re-evaluate distal pulses and motor and sensory function of the radial, median, and ulnar nerves.
• Post-Reduction Radiographs: Obtain AP and lateral radiographs to confirm proper joint alignment and rule out any associated fractures.

4. Immobilization

• Splinting:
  • Use a posterior mold splint to immobilize the elbow at 90° of flexion.
  • Position the forearm based on ligament involvement:
    • LCL Disruption: Place the forearm in pronation for stability.
    • MCL Disruption: Place the forearm in supination if the medial ligament is unstable.
• Duration:
  • Immobilize the elbow for a short period (5-10 days) to allow for initial healing while avoiding long-term stiffness.
  • Early Mobilization: Begin supervised range-of-motion exercises early to prevent joint stiffness and improve long-term function.

5. Follow-Up and Rehabilitation

• Early Motion: Start active and active-assisted ROM exercises within a safe arc, typically under the guidance of a physical therapist.
• Extension Block Brace: Consider using an extension block brace for 3-4 weeks if there is concern for joint instability in extension.
• Radiographic Follow-Up: Obtain additional radiographs at 3-5 days and again at 10-14 days post-reduction to ensure joint congruency is maintained and check for any delayed complications.

And Alternative way

https://www.youtube.com/watch?v=MAKqZZrzdOE&ab_channel=FIFA

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Key Points for Successful Reduction

• Adequate Sedation and Muscle Relaxation are critical for achieving a smooth reduction.
• Maintaining Inline Traction and Supination while guiding the olecranon back with elbow flexion ensures the coronoid process returns under the trochlea.
• Post-Reduction Stability Testing is essential to assess for ligamentous injury, and immobilization positioning should account for any ligamentous disruption.
• Early Mobilization is crucial to prevent stiffness and achieve optimal functional recovery.

By following these steps, you can ensure a systematic approach to diagnosing and reducing a posterior elbow dislocation, optimizing patient outcomes and minimizing complications such as joint stiffness and instability.

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Steps to Apply an Elbow Slab for Dislocation (Covering One Joint Above and Below)

1. Preparation

1. Gather Supplies:
   • Plaster of Paris or fiberglass slab (cut to appropriate length).
   • Padding (e.g., cotton or synthetic padding).
   • Elastic or crepe bandages to secure the slab.
   • Basin of water for wetting the slab if using plaster of Paris.
   • Scissors to adjust the slab size as needed.
   • Arm sling for additional support after slab application.
2. Patient Positioning:
   • Elbow Flexion: Seat the patient comfortably, positioning the elbow at approximately 90 degrees of flexion.
   • Forearm Position (Neutral):
     • If ligament stability is unknown, keep the forearm in a neutral position (thumb pointing upward).
     • If ligament stability is known:
       • Pronation for LCL (Lateral Collateral Ligament) injuries.
       • Supination for MCL (Medial Collateral Ligament) injuries.
3. Measurement and Slab Preparation:
   • Measure the length of the slab to cover one joint above and one joint below:
     • Extend from the mid-upper arm (covering part of the humerus) to the base of the hand (wrist).
   • Cut the slab to this measured length.

2. Application of the Slab

1. Apply Padding:
   • Wrap padding around the arm from mid-upper arm down to the wrist, covering the elbow joint adequately.
   • Add extra padding over bony prominences like the olecranon (tip of the elbow), medial and lateral epicondyles to prevent pressure sores.
   • Ensure that the padding is smooth and not too tight to avoid restricting circulation.
2. Prepare the Slab:
   • If using plaster of Paris, dip the slab in water to activate it, then gently wring out excess water.
   • Avoid excessive water as it can delay the setting and make the slab too heavy.
3. Position and Mold the Slab:
   • Place the slab along the posterior aspect of the arm, from mid-upper arm down to the wrist.
   • Mold the slab to fit the contours of the arm without applying excessive pressure.
   • Maintain 90 degrees of elbow flexion and ensure the forearm is in neutral position unless ligament stability has been confirmed.
4. Secure with Bandage:
   • Wrap an elastic or crepe bandage over the slab, beginning from the wrist and moving up toward the upper arm.
   • Wrap firmly but not too tight, allowing for swelling and monitoring circulation.
   • Leave a portion of the slab exposed to check for proper alignment and ensure visibility of the arm.

Applying a slab can be challenging; please refer to this instructional video on the method for folding and preparing the cast before immersion in water: https://youtu.be/jk0Nv8oXV60?si=xEDFxcjX_Me6bGZ9&t=92

and https://youtu.be/-xfpUKv1_A8?si=jkUjj-CLXS2smZGP&t=3

3. Final Checks and Arm Sling Application

1. Assess Circulation and Fit:
   • Check capillary refill at the fingertips to ensure adequate circulation.
   • Ask the patient to report any numbness, tingling, or discomfort, which may indicate that the bandage is too tight.
   • Make sure the slab is immobilizing the elbow, limiting movement at both the elbow and wrist.
2. Apply an Arm Sling:
   • Place the arm in a sling to support the slab and maintain the elbow at 90 degrees.
   • Adjust the sling to elevate the hand slightly above the elbow level, helping reduce swelling.
   • Instruct the patient to keep the arm relaxed and supported in the sling at all times.
3. Patient Instructions:
   • Advise the patient to keep the slab dry and avoid applying weight on the immobilized arm.
   • Instruct them to return if they experience increased pain, swelling, numbness, or discoloration of the fingers, as these may indicate complications.

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Key Points for Effective Slab Application

• Neutral Position for Unknown Stability: Position the forearm in neutral (thumb facing up) when the stability of ligaments is uncertain.
• Elbow Flexion at 90 Degrees: Always maintain 90 degrees of flexion unless otherwise specified for specific ligament injuries.
• Arm Sling for Support: The sling is essential to support the arm, maintain correct positioning, and reduce strain on the shoulder.
• Circulation Monitoring: Regularly check capillary refill and encourage the patient to report any discomfort, as slabs can tighten as they dry.

By following this method, you ensure comprehensive immobilization and support for an elbow dislocation, adhering to best practices and maximizing patient comfort and safety.

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Orthopedic-Level Patient Instructions for Elbow Dislocation Slab

1. Purpose of the Slab

• The slab is a partial cast designed to immobilize your elbow and allow proper healing. It restricts movement, providing stability and support to the injured joint, ligaments, and muscles.
• This immobilization is crucial to prevent further injury to the elbow structures and to control pain and swelling during the initial healing phase.

2. Positioning and Support

• Elbow Position: Keep your elbow bent at approximately 90 degrees at all times. This position stabilizes the elbow joint and reduces strain on the ligaments and other soft tissues.
• Hand Position (Neutral):
  • Thumb Up: Keep your thumb pointing up, with your palm resting near your abdomen.
  • Fingers Down: The fingers should point downward in a relaxed, natural position.
  • Dorsal Side of Hand Slightly Outward: The back of your hand should face outward, away from your body.
• Arm Sling:
  • Wear the sling provided to support the arm and maintain the elbow at 90 degrees.
  • Adjust the sling so that your hand is slightly elevated above your elbow. This helps reduce swelling by allowing blood to flow away from the hand.

3. Care of the Slab

• Keep the Slab Dry:
  • Waterproofing: Moisture can weaken the plaster or fiberglass and cause skin irritation. Use a plastic bag or waterproof cover over the slab while showering.
  • No Water Exposure: Avoid any water exposure, including rain or splashes, as wetting the slab can lead to skin breakdown.
• Avoid Inserting Objects:
  • Itching may occur under the slab, but never insert objects (such as pens, pencils, or hangers), as this can damage the skin and lead to infection.
• No Pressure on the Slab:
  • Avoid resting heavy objects on the slab, and do not lean on it, as excessive pressure could alter its shape and reduce its effectiveness.
• Check for Tightness:
  • The slab may feel snug if swelling occurs. However, it should not feel uncomfortably tight. If tightness worsens or persists, elevate the arm and check circulation as described below.

4. Monitoring for Complications

• Signs of Circulation Problems:
  • Check Fingers: Your fingers should stay pink and warm to the touch. Check circulation by pressing on the nail beds (capillary refill); color should return within 2 seconds.
  • Observe for Pallor or Coldness: If your fingers turn pale, blue, or feel cold, this may indicate restricted blood flow.
• Signs of Nerve Compression:
  • Numbness, tingling, or increased pain in the fingers or hand can suggest nerve compression. If these symptoms persist or worsen, contact your healthcare provider immediately.
• Swelling:
  • Some swelling is expected initially. To control swelling, keep your arm elevated above heart level as much as possible, especially in the first 48 hours.

5. Compartment Syndrome (Red Flag)

Compartment syndrome is a medical emergency where pressure builds up in the muscles, potentially causing severe tissue damage. Be vigilant for these warning signs and seek immediate medical attention if they occur:

• Severe Pain (Out of Proportion): If pain becomes increasingly intense, doesn’t respond to medication, or worsens with movement or touch, this is a warning sign.
• Paresthesia (Tingling or Numbness): Persistent tingling, numbness, or “pins and needles” sensation in the fingers.
• Pallor (Pale Skin): Skin that appears pale, blue, or mottled.
• Paralysis (Weakness): Difficulty moving the fingers or wrist, or a feeling of weakness.
• Pulselessness (Loss of Pulse): A weak or absent pulse is a very late and dangerous sign.

If any of these symptoms occur, go to the emergency room immediately. Compartment syndrome can lead to permanent damage if not treated promptly.

6. Activity Limitations

• Avoid Using the Affected Arm:
  • Do not lift, push, or carry objects with the injured arm. Any weight-bearing activity could disrupt the healing process and lead to re-injury.
• Avoid Excessive Movement:
  • Minimize movement of the elbow, wrist, and hand. Follow your doctor’s instructions for when and how to begin any movement or physical therapy.
• Driving Restrictions:
  • Driving is not advised while the slab is in place, as sudden pain or limited mobility could impact your ability to drive safely.

7. Pain and Discomfort Management

• Pain Medication:
  • Take any prescribed pain medication as directed to manage pain and inflammation effectively.
• Elevation:
  • Keep the arm elevated as much as possible, especially in the first 48 hours, to reduce swelling and discomfort.
• Ice Application:
  • Apply ice to the area around the slab (not directly on it) for 15-20 minutes every 2-3 hours during the first 48 hours if recommended. Use caution to avoid moisture on the slab.

8. Follow-Up Appointments and Rehabilitation

• Attend All Follow-Up Visits:
  • These appointments are critical for assessing healing progress. X-rays or further evaluation may be necessary to confirm proper alignment and assess for any complications.
• Rehabilitation:
  • Physical therapy will likely be initiated once the initial healing phase is complete to gradually restore movement and strength. Extended immobilization can lead to joint stiffness, so early mobilization is often recommended.
• Extension Block Brace (if prescribed):
  • In some cases, an extension block brace may be used during early rehabilitation to limit extension and protect the joint. Your provider will guide you on if and when this is needed.

9. Signs to Seek Immediate Medical Attention

• Increased or Unmanageable Pain: Especially if it doesn’t improve with medication and elevation.
• Changes in Skin Color or Temperature: Pale, cold, or blue fingers.
• Persistent Numbness or Tingling: This may indicate nerve compression.
• Persistent Swelling and Tightness: Swelling that does not improve or worsens with elevation.
• Signs of Infection: Redness, warmth, or drainage from beneath the slab, especially if accompanied by fever.

Final Takeaway

Your slab is crucial to stabilizing your elbow and allowing it to heal correctly. Following these detailed instructions and monitoring for any red-flag symptoms will help ensure a safe and effective recovery. If you have questions or concerns, reach out to your healthcare provider promptly to address any issues that may arise.

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คำแนะนำสำหรับผู้ป่วยที่ใส่เฝือก Slab หลังเคลื่อนข้อศอก (ภาษาไทย)

1. วัตถุประสงค์ของเฝือก Slab

• เฝือกนี้จะช่วย ตรึงข้อศอก เพื่อป้องกันการเคลื่อนไหว ลดอาการบวม และช่วยให้โครงสร้างภายในข้อศอกที่บาดเจ็บฟื้นตัวได้เร็วขึ้น

2. ตำแหน่งและการรองรับ

• รักษามุมข้อศอกไว้ที่ 90 องศา โดยให้ข้อศอกงอในตำแหน่งกลาง (นิ้วโป้งชี้ขึ้น) และใช้ สลิงพยุงแขน โดยปรับให้มือสูงกว่าข้อศอกเล็กน้อยเพื่อลดบวม

3. การดูแลเฝือก Slab

• ห้ามให้เฝือกโดนน้ำ: ใช้ถุงพลาสติกคลุมเฝือกขณะอาบน้ำเพื่อป้องกันน้ำเข้าซึม
• ห้ามแหย่วัตถุเข้าไปในเฝือก: เช่น ดินสอหรือปากกา เพราะอาจทำให้เกิดแผลและการติดเชื้อ
• ตรวจสอบความแน่น: หากเฝือกรัดแน่นเกินไป ให้ยกแขนสูงเพื่อลดบวม หากยังรู้สึกแน่นอยู่ ให้ติดต่อแพทย์ทันที

4. การสังเกตภาวะแทรกซ้อน

• การไหลเวียนโลหิต: ตรวจสอบสีของนิ้วมือ (ควรเป็นสีชมพู) และกดเล็บเพื่อตรวจสอบการไหลเวียนเลือด หากสีกลับมาไม่เกิน 2 วินาทีถือว่าปกติ
• อาการชาและรู้สึกเสียวแปลบ: หากมีอาการชาเพิ่มขึ้นหรือรู้สึกเสียวแปลบ ควรติดต่อแพทย์
• การบวม: หากบวมมากขึ้นหรือแน่นขึ้นแม้จะยกแขนแล้ว ควรติดต่อแพทย์

5. ภาวะฉุกเฉิน: ภาวะ Compartment Syndrome

ภาวะนี้เป็นเหตุฉุกเฉิน ที่เกิดจากความดันสูงในกล้ามเนื้อ หากไม่รักษาทันทีอาจเกิดการบาดเจ็บถาวรได้ โดยอาการที่ต้องระวัง ได้แก่:

• ปวดรุนแรงเกินปกติ: อาการปวดที่รุนแรงและไม่บรรเทาด้วยยาหรือการพัก
• อาการชา: รู้สึกเสียวแปลบหรือชาที่นิ้วมือ
• นิ้วซีดหรือเย็น: นิ้วมือเปลี่ยนเป็นสีซีดหรือเย็นลง
• อ่อนแรง: เคลื่อนไหวนิ้วมือได้ยากขึ้น
• ไม่มีชีพจรที่ข้อมือ: หากไม่สามารถคลำชีพจรที่ข้อมือได้ให้รีบไปโรงพยาบาลทันที

6. ข้อจำกัดในการใช้งานแขน

• ห้ามใช้แขนข้างที่ใส่เฝือก: อย่ายกหรือแบกของหนักด้วยแขนข้างที่บาดเจ็บ
• หลีกเลี่ยงการขับขี่: งดขับรถในขณะที่ใส่เฝือก เนื่องจากอาจมีข้อจำกัดในการเคลื่อนไหวและการควบคุมรถ

7. การจัดการความปวดและการบวม

• ยาระงับปวด: รับประทานยาตามที่แพทย์สั่งเพื่อบรรเทาอาการปวด
• ยกแขนสูง: ยกแขนให้อยู่เหนือระดับหัวใจเพื่อลดการบวม
• ประคบเย็น: สามารถประคบเย็นรอบๆ เฝือกได้ครั้งละ 15-20 นาที ทุก 2-3 ชั่วโมง (ระวังอย่าให้เฝือกเปียก)

8. นัดติดตามผล

• มาพบแพทย์ตามนัดเพื่อประเมินการฟื้นตัว แพทย์อาจสั่งให้ถ่ายภาพรังสีเพื่อดูตำแหน่งของกระดูก และให้คำแนะนำเพิ่มเติมเกี่ยวกับการทำกายภาพบำบัดเมื่อต้องเริ่มเคลื่อนไหว

9. สัญญาณที่ควรไปพบแพทย์ทันที

หากพบอาการดังต่อไปนี้ ควรรีบไปพบแพทย์ทันที เนื่องจากอาจบ่งบอกถึงภาวะแทรกซ้อนที่ต้องการการดูแลฉุกเฉิน:

1. ปวดรุนแรงมากขึ้นหรือปวดไม่ทุเลา: โดยเฉพาะหากอาการปวดไม่ดีขึ้นหลังจากใช้ยาและการยกแขนสูง
2. การเปลี่ยนแปลงของสีผิวหรืออุณหภูมิที่นิ้ว: นิ้วมือซีด, เย็น หรือมีสีม่วงคล้ำ อาจแสดงถึงปัญหาการไหลเวียนเลือด
3. อาการชาหรือรู้สึกเสียวแปลบอย่างต่อเนื่อง: อาจเป็นสัญญาณของการกดทับเส้นประสาท
4. บวมแน่นอย่างต่อเนื่อง: หากอาการบวมไม่ลดลงหรือแย่ลงแม้จะยกแขนสูง
5. สัญญาณของการติดเชื้อ: มีรอยแดง, อุ่น หรือมีหนองไหลออกมาจากใต้เฝือก โดยเฉพาะหากมีไข้ร่วมด้วย