Arterial Injury
Brachial artery can be injured in dislocation of the elbow because of its vicinity. It can occur independently or along with nerve injury.
The first time the injury would, be evident is clinical examination of the affected extremity. The affected limb would be cold or would have lesser temperature as compared to opposite limb. On examination, distal pulses would be absent. However presence o pulses do not rule out vascular injury per se. It is necessary to examine for signs of increased compartment pressure in the forearm and hand. Pain with gentle passive extension of the digits is the most important early indicator of ischemia.
The elbow needs to investigated as that without injury. Loss of pulse does not preclude attempted closed reduction.
After the diagnosis has been made, the elbow should be gently reduced. If the pulse at the wrist does not return after the reduction, patient should be investigated for arterial injury. Doppler and arteriogram would help to delineate the culprit area.
Once the lesion has been identified, the patient should be prepared for immediate arterial reconstruction with saphenous vein grafting. If angigraphy delays the prompt treatment, it should be perormed in operating room.
Volar forearm fasciotomy [A surgery to relax the tight compartments of the forearm] should be performed concomitantly with vascular repair to improve the perfusion and reduce the chance of Volkmann’s contracture, a condition that develops due to ill perfusion can lead to deformity of the hand and forearm rendering it unusable.
Arterial repair with saphenous vein grafting is the standard of care. If the zone of injury is quite extensive, and if full mobility after repair is attempted, the reconstructed vessel must have adequate length to permit full extension. Occasionally no graft is needed.
Vigilance for loss of circulation after reduction due to intimal injury is important.
Nerve Injury
All the nerves surrounding the lower part of humerus i.e. median, ulnar, radial, and anterior interosseous nerves are vulnerable to injury in elbow dislocationare.
In addition to injury, the nerve can be affected at the time of reduction.
A detailed nerve examination should be done at the first encounter with the patient. Similarly, an examination after the reduction of the dislocation should be done.
If a nerve is injured at the time of injury and does not improve after the reduction, it is best for to wait and watch for recovery. If no sign of recovery is noted till 3 months, an operation should be considered.
In case of open injury, early exploration should be done.
In case the injury to nerve occurs at the time of reduction, exploration is indicated.
Join Discussions