Subluxation of the elbow

Anatomy of the elbow – why stability is so important

The elbow consists of three partial joints: the hinge joint between the upper arm bone (humerus) and the ulna, the joint between the humerus and the radius (radius), and the proximal radius-ulnar joint (radioulnar joint). The capsule, ligaments and muscles are crucial for stability.

• Lateral ligament complex (LCL, including lateral-ulnar collateral ligament): prevents tipping outwards and posterolateral rotational instability.
• Medial ligament (UCL/MCL): stabilizes during valgus stress (e.g. throwing movements).
• Annular ligament (annular ligament): holds the radius head on the ulna - centrally in pediatric radial head subluxation.
• Muscular stabilizers: triceps, biceps, forearm flexors/extensors and the rotators of the forearm axis.

If the ligaments are overstretched or torn, the joint structure can “give way” for a short time. A subluxation is the result of such a loss of stability.

What is Elbow Subluxation?

A subluxation is an incomplete dislocation: the joint surfaces lose normal contact but partially remain together. In contrast, dislocation is a complete dislocation. The elbow has different shapes:

• Radial head subluxation (children, “pulled elbow”): spoke head partially slides under the annular ligament.
• Posterolateral rotational instability (PLRI, more common in adults): Partial outward tilting of the forearm due to insufficiency of the lateral ligament complex.
• Valgus-associated subluxation (e.g. overhead sports): medial ligament insufficiency with pain/feeling of instability during throwing movements.

Subluxations can occur once after trauma or as recurring instability. Both variants should be clarified orthopedically.

Typical symptoms

• Sudden shooting pain in the elbow, often during twisting or supporting movements
• Sensation of “breaking away” or snapping, occasionally audible clicking
• Restriction of movement (stretching, bending, turning the forearm)
• Uncertainty/instability under stress, especially a. during supporting and throwing movements
• Swelling, tenderness on the side (lateral) or inside (medial)
• For children: protective posture with the arm hanging, slightly bent and pronated; Crying when trying to move

Warning signs of vascular/nerve involvement include numbness, tingling, paleness or coldness of the hand as well as severe misalignment - then please seek medical advice immediately.

Causes and risk factors

• Pulling/twisting trauma: sudden pulling on the forearm (common in children), falling onto the hand, twisting during sports
• Ligament overstretch or tear (LCL, UCL, annular ligament)
• Repeated overhead loads (throwing, racket sports), microlesions
• Previous injuries, instability after dislocation or fracture
• General connective tissue laxity (e.g. hypermobility spectrum)
• Accompanying joint changes (e.g. free joint bodies, cartilage damage) with pinching phenomenon

In children, radial head subluxation is usually the result of a pull on the hand. In adults, ligament lesions and recurring stress situations are the most common.

Examination and diagnostics

First, we take a detailed anamnesis: mechanism of the accident, location of pain, feeling of instability, previous injuries and sporting stress. This is followed by a physical examination with functional, stability and blood circulation/nerve tests.

• Special tests: e.g. B. Posterolateral rotation stress test (PLRI), valgus/varus stress test
• Palpation of the ligament attachments (lateral/medial), examination of forearm rotation
• Neurovascular control (blood circulation, sensitivity, motor skills)

Imaging depends on the findings and question:

• X-ray: rule out fractures/dislocations, assess the joint position
• Ultrasound: dynamic assessment of ligament structures, especially a. in children
• MRI: Evidence of ligament lesions (LCL/UCL), cartilage/soft tissue damage, loose joint bodies
• CT (rare): for complex bony issues

In the case of the typical radial head subluxation in children, the diagnosis is often successful clinically; Imaging is then only necessary if the course of the disease is unclear or concomitant injuries are suspected.

Conservative treatment – ​​standard of first choice

Most subluxations can be successfully treated conservatively. The aim is to reduce pain, restore stable joint function and prevent recurrences.

• Acute measures: relief, cooling, if necessary elastic bandage, elevation
• Medication: short-term anti-inflammatory painkillers according to individual medical recommendations
• Repositioning of radial head subluxation (children): gentle, targeted maneuvers by experienced doctors; usually immediate improvement
• Short-term immobilization: e.g. B. Sling/orthosis for a few days to relieve pain
• Physiotherapy: painless mobilization, stabilization of the lateral/medial complex, neuromuscular training, proprioception
• Load control: temporary break from sports; gradual re-entry
• Taping/Orthoses: situational support for everyday or sports stress

In selected chronic cases with ligament irritation, additional injection treatment can be considered. Regenerative procedures (e.g. PRP) are cautiously considered if there is no improvement with structured therapy and appropriate indication; The evidence is heterogeneous depending on the findings and will be discussed with you on a case-by-case basis.

When is it an emergency?

• Significant misalignment, suspected complete dislocation or fracture
• Severe, increasing pain, rapidly increasing swelling
• Numbness, signs of paralysis, pale/cold hand or no pulse
• Open injury
• Child with inconsolable pain and refusal to move his arm after pulling – see a doctor promptly

If you see these signs, please seek medical advice quickly. A safe reduction belongs in experienced hands.

Surgical options – only if there is a clear indication

Surgery is considered if, despite consistent conservative treatment, there is relevant instability, pain or recurrent subluxations or if structural damage suggests this.

• Reconstruction/refixation of the lateral ligament complex (LCL), e.g. B. in posterolateral rotational instability
• UCL reconstruction for severe medial instability in overhead sports
• Adjustment/refixation of the annular ligament in rare chronic cases
• Arthroscopy: Treatment of free joint bodies, cartilage/soft tissue renovation

This is followed by a graduated rehabilitation program with an initial protective phase, followed by active stabilization and sport-specific development.

Course, prognosis and risk of recurrence

In children with radial head subluxation, immediate relief of symptoms is often observed after successful reduction. In the short term, it may make sense to take it easy. Repetitions are possible, especially when pulling the arm again.

In adults, recovery depends on the extent of the ligament injury and muscular stability. In many cases, with conservative therapy, resilient function can be achieved within 6-12 weeks. Early functional, well-guided rehabilitation reduces the risk of recurrence.

• Risk factors for recurrences: inadequate muscle development, early overload, ligament laxity, persistent loose joint bodies
• Return-to-Sport: individually, after stress-free functional development and sport-specific tests

Rehabilitation and exercises

Exercises should be pain-adapted and professionally guided. Example building blocks:

• Isometric elbow extension/flexion exercises at pain-free angles
• Forearm pronation/supination with light resistance (Theraband), slow, controlled execution
• Stabilization of the wrist extensors/flexors for lateral/medial relief
• Scapular and trunk stability (scapula setting, serratus/rotator cuff) to improve the entire chain
• Proprioception: closed chain with light support load, later dynamic on unstable surfaces
• Sport-specific structure with technical training (e.g. throwing mechanics)

Only increase if there are no symptoms and consult with the treatment team to avoid relapses.

Prevention: What you can do yourself

• Never pull children up by their outstretched arm or jerk them
• Warm-up and technique training before exercise, especially a. with overhead loads
• Regular strength and coordination training for the forearm, shoulder and torso
• Dose stress, take breaks, take symptoms of overload seriously
• If you feel unstable, seek early orthopedic evaluation

Special situations: children, sports and everyday life

Children: Radial head subluxation usually occurs between 1 and 5 years of age. Parents notice a hanging, barely moving arm. After professional reduction, function is usually quickly restored. An imaging examination is only necessary if the course is atypical.

Sport: For overhead athletes, the entire kinetic chain (scapula, trunk, hips) should be trained in addition to the elbow. A return to play takes place gradually, accompanied by performance diagnostics and without time pressure.

Everyday life/work: Ergonomic adjustments, breaks and targeted strength training reduce discomfort during repetitive activities.

Your orthopedic care in Hamburg

In our practice at Dorotheenstrasse 48, 22301 Hamburg, we clarify elbow problems in a structured manner - with a focus on conservative, guideline-oriented treatment. In the event of complex instabilities, we will coordinate further steps with you transparently.

• Careful clinical examination and individually selected imaging
• Structured physiotherapy and training plans
• Targeted, evidence-based additional procedures only after benefit-risk assessment
• Interdisciplinary collaboration in sports and work stress