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Intra-articular Nerve Entrapment Is Possibility After Spontaneous Reduction of Elbow Dislocation
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Posted on: 11/30/1999
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Elbow dislocations can happen easily to children and sometimes, the elbow "pops" back into place on its own before the child is seen by a doctor. While this spontaneous reduction of the dislocation may be less traumatic for the child than having to have a doctor reduce the dislocation (put it back), there is a rare complication called intra-articular incarceration of the median nerve. This means that the median nerve that passes through the elbow, down the arm, becomes trapped. Unfortunately, this can't be seen while the child is being examined just after the injury occurred. The authors of this article describe a case study of a four-year-old boy who had a spontaneous reduction and an incarceration of the medial nerve.
The child had fallen out of a wheel barrow and landed on his outstretched hand. When his parents brought him to the emergency, x-rays did not show any dislocation or fracture, but there was some joint effusion, fluid on the joint. The boy had significant burning pain around the right elbow and he refused to move it. The elbow was tender to touch and there was restricted passive range of motion, meaning that when the doctor tried to move the arm, the motions were not a wide as they are normally.
The final diagnosis was a small fracture of the upper part of the humerus (forearm bone) and a half-splint was applied. On follow up visits, the boy showed signs of nerve damage, including the inability to bend his second and third fingers (pointing and middle fingers). His wrist was weak to bend and turn. X-rays did not show anything out of the ordinary. At this point, the doctors felt that the nerves would recover on their own so the splint was left on for additional time.
Six months after the initial fall, there were still problems with the nerve conduction to the wrist and fingers. After eight months, the doctors found that the nerve had been trapped and they had to do a osteotomy (bone had to be cut) to free the nerve. A cast was applied for two weeks and after six weeks, the boy was able to move his elbow completely. Fourteen months after surgery, his fingers and wrists have improved but there is still some muscle atrophy, wasting.
The authors note that anyone who presents with a nerve problem after they dislocated a joint should be followed closely to avoid longer than necessary diagnosis of nerve entrapment. Once the diagnosis has been made, surgery is usually needed to free the nerve and prevent further damage. The surgery may be difficult, given the scar tissue, limited space, and flattened nerve.
Rehabilitation after this type of surgery should involve splinting the joint for a short period to allow for wound healing, followed by physiotherapy (at home or at a clinic or hospital) to encourage new movement and regaining of range of motion.
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References:
Dave Simon, MD, et al. Intra-articular Median Nerve Incarceration After Spontaneous Reduction of a Pediatric Elbow Dislocation: Case Report and Review of the Literature. In Journal of Pediatric Orthopaedics. March 2010. Vol. 30, No. 2. Pp. 125-129.
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