CASE REPORTS Acute brachialis muscle rupture caused by closed elbow dislocation in a professional American football player Aaron J. Krych, MD a, *, Robert B. Kohen, MD b , Scott A. Rodeo, MD b , Ronnie P. Barnes, ATC c , Russell F. Warren, MD b , Robert N. Hotchkiss, MD b a Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA b Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA c New York Football Giants, TIMEX Performance Center, East Rutherford, NJ, USA Injury to the brachialis muscle is rare, with only several patients with isolated injury reported. 12,14,15 The brachialis muscle is anatomically close to the anterior capsule and the joint of the elbow, placing the muscle at risk during elbow dislocation; however, this has never been described. In contrast, elbow dislocations have an incidence of approxi- mately 6 per 100,000, making them the second most frequent dislocations encountered after shoulder disloca- tions. 6 Most elbow dislocations affect young adults, often involved in a sports injury. 4 In most individuals, these injuries involve only the joint and carry a good prognosis after reduction, brief immobilization, and active rehabili- tation. 5,10,11,13 Most of the current studies emphasize the indications and outcomes of repairing the ligaments or in restoring motion of the elbow joint. We report a brachialis muscle rupture associated with closed elbow dislocation and the results of surgical repair in a high-demand professional athlete. Case report A 23-year-old, right-hand-dominant professional American foot- ball player (linebacker) sustained a closed elbow dislocation during on-field play. Before this injury, the patient had no prior injury to the elbow or arm. The patient was taken to the training room, and a closed reduction was performed by gently recreating the hyperextension position with longitudinal traction, followed by flexing the joint. No neurovascular injury was apparent before or after reduction. Achieving reduction seemed at the time more difficult than usual, requiring more traction. After reduction, the joint did not redislocate or subluxate in a range of 20  to 90  . No fractures were noted on postreduction radiographs, including of the coronoid process or radial head. The elbow was immobilized using a posterior splint and sling. The degree of swelling seemed commensurate with the injury, and the patient was observed for signs of impending neurovascular impairment and compartment syndrome; none occurred. The mechanism of injury became clear after review of the game video. He received a direct blow to the posterior (dorsal) elbow with the joint fully extended and the hand planted on the turf. The blow appeared to force hyperextension and anterior displacement of the distal humerus, resulting in a posterior dislocation of the elbow. A magnetic resonance image (MRI) was obtained the day after the injury. As expected, the posterolateral ligament complex was avulsed from the humeral origin, and the medial collateral liga- ment was also torn. Unexpectedly, the distal third of the brachialis muscle was completely torn, with a measured gap of 2.75 cm on MRI with the joint flexed at 80  (Fig. 1). Upon re-examination, the gap was palpable 5 cm proximal to the antecubital fold. At our institution, we reviewed the MRI findings in 30 cases of previous elbow dislocation, but did not find a single patient with brachialis muscle rupture. Owing to the player’s high-demand physical activities, he underwent surgical repair of the brachialis muscle and possible ligament repair, depending on the intraoperative stability. After ultrasound-guided infraclavicular anesthesia was ach- ieved, the elbow was examined by gently extending the joint in the supine position, without varus or valgus stress. No subluxation or This study was approved by the Hospital for Special Surgery Investiga- tional Review Board (Study No. 11010). *Reprint requests: Aaron J. Krych, MD, Mayo Clinic, Department of Orthopedic Surgery, 200 First St SW, Rochester, MN 55905, USA. E-mail address: krych.aaron@mayo.edu (A.J. Krych). J Shoulder Elbow Surg (2012) 21, e1-e5 www.elsevier.com/locate/ymse 1058-2746/$ - see front matter Ó 2012 Journal of Shoulder and Elbow Surgery Board of Trustees. doi:10.1016/j.jse.2011.11.007