Polodoc: Elbow Out

from Polo Times September 2022

The 2022 Pony Club Polo Championships

Dr.med. Andreas Krüger is a Swiss board orthopaedic and trauma surgeon in Zurich, who specialises in knee and shoulder surgery. Andi is a second generation of tournament doctors for equine sports, known as Polodoc since 2013

Elbow Out

A real emergency – difficult to treat

If the legs in polo belong to the horses then the upper extremity belongs to the player. From the upper extremity, the arms are most exposed to trauma. Either during the rideoff or through hits with the mallet. Highest levels of loading happen during the landing procedure when dismounting unexpectedly from the horse. Axial loading is transferred from the hand to the trunk and energy flows through the elbow. When overloading happens to the joint, either the bone structure or the soft tissue, such as the joint capsule or the restraining ligaments, break. The soft tissue is weaker than the bone and a dislocation occurs. The articulating hard structures lose contact and ligaments break down. This can also happen in a combination when a fracture of the bone and a rupture of ligaments happens – a real disaster. If this elbow dislocation happens, even in a short time frame nerve damage can happen. An uncomplicated dislocation itself is not easy to treat and needs a lot of therapy to recover.

Anatomy

Three bones come together in the elbow joint. The humerus is the bone in the upper arm and the two bones from the forearm (the radius and the ulna) form the lower part of the elbow. Ligaments connected to the bones on the inner and the outer site keep the elbow joint together while moving. The elbow is both a hinge joint and a ball and socket joint. Bending occurs through a hinge joint that allows the elbow to flex and extend the arm. Rotation occurs though a ball and socket joint that allows the hand to be rotated palm up and palm down.

Injury Pattern

Elbow dislocations typically occur when a player falls onto an outstretched hand. When the hand hits the ground, the force is sent to the elbow. Usually, there is a turning motion in this force. This can drive and rotate the elbow out of its socket. The force that is sent through the arm can dislocate the elbow, just as in a fall. The elbow is stable because of the combined stabilizing effects of bone surfaces, ligaments, and muscles. When an elbow dislocates, any or all of these structures can be injured to different degrees.

Full elbow dislocation

A simple dislocation does not have any major bone injury. A complex dislocation can have severe bone and ligament injuries. In the most severe dislocations, the blood vessels and nerves that travel across the elbow may be injured. If this happens, there is a risk of losing the arm. A complete elbow dislocation is extremely painful and obvious. The arm will look deformed and may have a weird looking twist at the elbow.

Partial elbow dislocation (subluxation)

A partial elbow dislocation or subluxation can be harder to detect because the elbow is only partially dislocated, the bones can spontaneously relocate, and the joint may appear fairly normal. The elbow will usually move quite well, but there may be some restriction by pain. Typically, a hematoma may occur on the inside and outside of the elbow where ligaments may have been stretched or torn. Partial dislocations can continue to recur over time if the ligaments heal improper.

Clinical examination

During the physical examination of the arm for tenderness, swelling, and deformity. Skin,

Visible hematoma on the inside and outside of the elbow

circulation of the arm with pulses at the wrist will be checked. If the artery is injured at the time of dislocation, the hand will be cool to touch and may have a white or purple hue. This is caused by the lack of warm blood reaching the hand. It is also important to check the nerve supply to the hand. If nerves have been injured during the dislocation, the hand may be numb and not able to move.

Adjunct therapy with dry needling

Radiological work-up

X-ray is the primary examination to determine the bone injury. X-rays can also help show the direction of the dislocation. If bone detail is difficult to identify on an X-ray, a computed tomography (CT) can help. The evaluation of the ligaments is done with a magnetic resonance image (MRI).

Treatment

An elbow dislocation is a real emergency injury. The goal of immediate treatment is to return the elbow to its normal alignment. The long- term goal is to restore function and the full range of motion.

Nonsurgical treatment Repositioning of the elbow to the normal alignment is done in an emergency department at the hospital. Prior to the procedure, sedatives and pain medications usually will be given. It is done gently and slowly by pull.

After elbow reduction Simple elbow dislocations are treated by keeping the elbow immobile in a splint or sling for one week, followed by early motion exercises. If the elbow is kept immobile for a long time, the ability to move the elbow fully (range of motion) may be affected. Physical therapy is mandatory during this period of recovery. Secondary after the elbow’s range of motion has improved, a strengthening program is added. X-rays may be taken periodically while the elbow recovers to ensure that the bones of the elbow joint remain well aligned.

Surgical treatment In complex elbow dislocation, surgery may be necessary to restore bone alignment and repair ligaments. Realigning complex elbow dislocation is demanding. After surgery, the elbow is protected with an external hinge. This brace protects the elbow from redislocation. If blood vessel or nerve injuries are associated with the elbow dislocation, additional surgery may be needed to repair this. Late reconstructive surgery is indicated when instability remains after conservative treatment was unsuccessful, or when stiffness is relevant. This surgery removes scar tissue and extra bone growth. It also removes obstacles to movement. Over time, there is an increased risk for arthritis in the elbow joint if the alignment of the bones is not good; the elbow does not move and rotate normally; or the elbow continues to dislocate.

Recommendation

Elbow dislocation is a critical injury to the player’s arm and can be a sport-ending injury. Correct initial diagnosis and treatment is key to restore full range of motion and stability to maintain a strong arm for polo. Long interval until returning to play can happen when stiffness or instability remains. Multimodal treatment from specialised healthcare providers and current adjunctive treatments can help to speed up recovery and minimize the chance for complications.

For more information on Polodoc contact Andreas Krüger at drmedkrueger@gmail.com or www.polodoc.ch