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CASE REPORT
Year : 2018  |  Volume : 18  |  Issue : 1  |  Page : 55-57

A case report of divergent elbow dislocation of a child during school sports drill


Department of Orthopaedics, Government Medical College, Haldwani, Uttarakhand, India

Date of Web Publication15-Feb-2018

Correspondence Address:
Ganesh Singh Dharmshaktu
Ganga Vihar, Malli Bamori, Haldwani - 263 139, Uttarakhand
India
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DOI: 10.4103/sjsm.sjsm_37_17

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  Abstract 


Divergent dislocation of elbow is a rare injury with few reports or short series. These dislocations require prompt diagnosis with careful evaluation of radiographs and emergent reduction and splinting. Axial force overflexed or semi-flexed elbow may be initial mechanism that dislocates the elbow and propagation of force then separates radius and ulna as in our case. Injury in school drills are usually minor, but complex dislocation may occur in events involving somersault and backflips requiring caution for the prevention and urgent management. We, hereby, describe relevant details of transverse divergent elbow dislocation in a 10-year-old child with appropriate management leading to uneventful recovery and satisfactory functional outcome.

  Abstract in Arabic 

الخلع المتباين للكوع هو إصابة نادرة وردت في تقارير قليلة أو سلسلة قصيرة. هذه الاضطرابات تتطلب التشخيص الفوري مع تقييم اشعاعي دقيق من وتصحيح الخلع والتجبير. قد تكون القوة المحورية أو شبه الكوع المرن الآلية الأولية التي تخلع الكوع وانتشار القوة ثم يفصل بين عظم دائرة نصف قطرها والزند كما هو الحال في حالتنا. لإصابات في التدريبات المدرسية عادة ما تكون طفيفة، ولكن قد يحدث خلل معقد في الأحداث التي تنطوي على شقلبة أو حركة عكسية تتطلب الحذر للوقاية والعلاج العاجل. نحن، هنا، وصف التفاصيل في تقرير حالة ذات الصلة من عرضية متباعدة.

Keywords: Child, closed reduction, dislocation, divergent, elbow, injury


How to cite this article:
Dharmshaktu GS, Jhan A, Singh B, Bhandari SS. A case report of divergent elbow dislocation of a child during school sports drill. Saudi J Sports Med 2018;18:55-7

How to cite this URL:
Dharmshaktu GS, Jhan A, Singh B, Bhandari SS. A case report of divergent elbow dislocation of a child during school sports drill. Saudi J Sports Med [serial online] 2018 [cited 2018 Nov 17];18:55-7. Available from: http://www.sjosm.org/text.asp?2018/18/1/55/225293




  Introduction Top


Elbow dislocations are uncommon injuries in young children with a reported incidence of about 3% of all pediatric elbow injuries.[1],[2] Divergent dislocation involves dissociation of proximal radius and ulna from each other and humerus. The presentation usually is of displacement of radial head and proximal ulna toward lateral and medial aspect, respectively, with disrupted interosseous membrane between them.[3] It represents a serious injury with disruption of ligamentous stabilizers around the elbow with severing of the forearm interosseous membrane as validated in a cadaveric study.[4] Divergent dislocation is a variant of posterior elbow dislocation and is rare injury pattern. Only a few reports or series has been published about this rare dislocation.[5],[6],[7],[8]


  Case Report Top


A 10-year-old, otherwise healthy, male child was brought to us with a history of fall from a height on his backside while backflipping in a school sports event an hour back while his right upper limb was hit on a wall before finally landing on the ground on outstretched hands. The limb was held with a cloth sling, and there was painful limitation of movement and deformity at right elbow region. There was no associated injury, and distal neurovascular status was intact. The appropriate radiographs were advised which showed a posterior elbow dislocation on lateral view with dissociation of proximal radius and ulna on anteroposterior view [Figure 1]. The radius was displaced laterally and not aligned with the capitellar region, and proximal ulna was displaced medially. Medial and lateral condyles were normally placed and forearm bones were intact. The diagnosis of isolated transverse divergent dislocation was made, and the patient was planned for closed reduction under anesthesia after informed consent by parents for the procedure and probable future publication. The elbow was reduced by “puller” technique as advocated by Parvin in the supine position.[9] The additional compression of proximal radius and ulna together brought the reduction of dissociated bones along with elbow. The reduction was confirmed under image intensifier for adequacy and concentricity. A protective plaster backslab was given, with a sling following the procedure, and active movement of the fingers and shoulder encouraged to avoid stiffness. A full backslab above elbow was given to the patient for three weeks for soft-tissue healing [Figure 2]. The follow-up period was uneventful with marked decrease in pain and discomfort, and active range of motion exercises was started after removal of plaster and was encouraged at home. No immediate or remote complication of trauma or related to technique was noted in regular follow up visits till two years [Figure 3].
Figure 1: Radiograph showing posterior dislocation in lateral view and divergent dissociation of proximal radius and ulna in anteroposterior view suggestive of transverse divergent dislocation

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Figure 2: Postreduction radiograph showing well-reduced injury with temporary backslab that was converted to long above elbow plaster slab

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Figure 3: Follow-up radiograph at 2 years showing stable reduction and good clinical range of motion

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  Discussion Top


The divergent elbow dislocation, often caused by high-energy trauma, is a rare injury with few case reports or small series described in the literature.[3],[10],[11] The injury has been reported with other associated injuries like that of distal radial epiphysis.[12] Other concomitant injuries reported are fracture of radial neck, coronoid process, or upper ulna.[5],[11],[12],[13],[14] Our case had no such appreciable injuries. Most of such cases have been managed successfully with closed reduction. Failed reduction or displaced concomitant injuries have been managed operatively.[14],[15],[16] Interposed structures such as anterior band of medial collateral ligament have been implicated as cause to failed closed reduction in a report.[17] Management of associated injuries such as coronoid fracture has been found to be effective in reduction and retention of the reduction in a report.[18] The immediate reduction attempt in our case resulted in successful reduction in single attempt thus minimizing additional trauma to local structures. The compliant treatment was followed by supervised rehabilitation and physiotherapy and that one is also an integral component of optimal recovery. Overall results of the management of these injuries have been satisfactory if appropriately managed with the standard protocols. The complex injury patterns warrant meticulous management to all associated injuries to avoid late complications such as late symptomatic instabilities. The case highlights the importance of knowledge of rare patterns of common dislocations and early diagnosis and adequate management.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Henrikson B. Supracondylar fracture of the humerus in children. A late review of end-results with special reference to the cause of deformity, disability and complications. Acta Chir Scand Suppl 1966;369:1-72.  Back to cited text no. 1
[PUBMED]    
2.
Dharmshaktu GS, Singhal A, Khan I. Elbow dislocation in a 3 year old child: A report of a rare injury. Int J Contemp Pediatr 2015;2:254-6.  Back to cited text no. 2
    
3.
Stans AA, Lawrence JT. Dislocations of the elbows, medial epicondylar humerus fractures. In: Flynn JM, Skaggs DL, Waters PM, editors. Rockwood and Wilkins' Fractures in children. 8th ed. Philadelphia: Walter Kluwer Health; 2015.  Back to cited text no. 3
    
4.
Altuntas AO, Balakumar J, Howells RJ, Graham HK. Posterior divergent dislocation of the elbow in children and adolescents: A report of three cases and review of the literature. J Pediatr Orthop 2005;25:317-21.  Back to cited text no. 4
    
5.
Carey RP. Simultaneous dislocation of the elbow and the proximal radio-ulnar joint. J Bone Joint Surg Br 1984;66:254-6.  Back to cited text no. 5
    
6.
DeLee JC. Transverse divergent dislocation of the elbow in a child. Case report. J Bone Joint Surg Am 1981;63:322-3.  Back to cited text no. 6
    
7.
Andersen K, Mortensen AC, Grøn P. Transverse divergent dislocation of the elbow. A report of two cases. Acta Orthop Scand 1985;56:442-3.  Back to cited text no. 7
    
8.
Holbrook JL, Green NE. Divergent pediatric elbow dislocation. A case report. Clin Orthop Relat Res 1988;234:72-4.  Back to cited text no. 8
    
9.
Parvin RW. Closed reduction of common shoulder and elbow dislocations without anesthesia. AMA Arch Surg 1957;75:972-5.  Back to cited text no. 9
    
10.
Nakano A, Tanaka S, Hirofuji E, Yasuwaki Y, Yamamoto T, Kubota S, et al. Transverse divergent dislocation of the elbow in a six-year-old boy: Case report. J Trauma 1992;32:118-9.  Back to cited text no. 10
    
11.
Vicente P, Orduña M. Transverse divergent dislocation of the elbow in a child. A case report. Clin Orthop Relat Res 1993;294:312-3.  Back to cited text no. 11
    
12.
Shankarappa YK. Transverse divergent dislocation of the elbow with ipsilateral distal radius epiphyseal injury in a seven year old. Injury 1998;29:798-802.  Back to cited text no. 12
    
13.
Adams JE. Injury to the throwing arm. A study of traumatic changes in the elbow joints of boy baseball players. Calif Med 1965;102:127-32.  Back to cited text no. 13
    
14.
el Bardouni A, Mahfoud M, Ouadghiri M, Halhal M, el Yacoubi M, el Manouar M, et al. Divergent dislocation of the elbow. Apropos of a case. Rev Chir Orthop Reparatrice Appar Mot 1994;80:150-2.  Back to cited text no. 14
    
15.
McAuliffe TB, Williams D. Transverse divergent dislocation of the elbow. Injury 1988;19:279-80.  Back to cited text no. 15
    
16.
Nanno M, Sawaizumi T, Ito H. Transverse divergent dislocation of the elbow with ipsilateral distal radius fracture in a child. J Orthop Trauma 2007;21:145-9.  Back to cited text no. 16
    
17.
van Wagenberg JM, van Huijstee PJ, Verhofstad MH. Pediatric complex divergent elbow dislocation. J Orthop Trauma 2011;25:e5-8.  Back to cited text no. 17
    
18.
Zaricznyj B. Transverse divergent dislocation of the elbow. Clin Orthop Relat Res 2000;373:146-52.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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