Elbow Dislocation and Reduction

Clinical suspicion of acute anterior, posterior, lateral, medial, or divergent dislocation with or without neurovascular compromise

The clinical presentation depends on the type of dislocation

Suspected dislocation is clinically confirmed by disruption of the relationship between the tip of the olecranon and the distal epicondyles of the humerus in comparison with the unaffected elbow

Radiographic evidence of anterior, posterior, lateral, medial, or divergent dislocation (FIGURE 65.1)

CONTRAINDICATIONS

Open dislocations require emergent consultations with an orthopedic surgeon

Multiple failed reduction attempts with adequate sedation should prompt consultation with an orthopedic surgeon

Irreducible elbow dislocations may require operative management

An elbow that has been unreduced for 7 or more days will likely require open reduction with an orthopedic surgeon

RISKS/CONSENT ISSUES

Procedural sedation may be associated with loss of airway reflexes and respiratory arrest (these risks are extremely rare)

Soft-tissue injury may occur with reduction attempts

Fractures and neurovascular injury may occur with reduction attempts

General Basic Steps

Obtain necessary x-rays

Sedation/Analgesia

Position patient

Reduction

Postprocedure exam/x-rays

FIGURE 65.1 Posterior dislocation of the olecranon. (From Campbell C. Elbow dislocation. In: Greenberg MI, ed. Greenberg’s Text-Atlas of Emergency Medicine. Philadelphia, PA: Lippincott Williams & Wilkins; 2005:492, with permission.)

FIGURE 65.2 Elbow anatomy. (From McCue FC III, Sweeney T, Urch S. The elbow, wrist, and hand. In: Perrin DH, ed. The Injured Athlete. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 1999, with permission.)

TECHNIQUE

Perform a complete neurovascular check before any reduction attempt

Obtain radiographs of the affected joint and consider radiographs of one joint above and below the injury (shoulder and wrist)

Complex dislocations (those with associated fractures) may require consultation with orthopedic surgery

Dislocations with neurovascular compromise should be reduced without prior imaging

Anesthesia/analgesia: Consider parenteral analgesics. Reduction may also be attempted with injection of local anesthetic alone into the elbow joint or an ultrasound-guided brachial plexus block

Reduction technique is determined by the type of dislocation

TECHNIQUE: POSTERIOR DISLOCATION

80% to 90% of all elbow dislocations

Mechanism of injury: Most commonly caused by a fall on an outstretched hand with the arm in extension

Clinical presentation: Shortened forearm that is held in flexion with a prominent olecranon posteriorly. In addition, a defect may be palpable above the olecranon (FIGURE 65.2).

Associated injuries:

Fractures including radial head and coronoid process are common

Small fractures of the coronoid process may be treated as simple posterior dislocations

Neurologic symptoms accompany 15% to 22% of dislocations

Ulnar nerve injury is most common followed by median nerve injury

Radial nerve injury commonly occurs when the dislocation is complicated by radial head fracture

Traction leading to stretch injury, local swelling, and entrapment during reduction are common causes of nerve injury

Brachial artery injury occurs in 5% to 13% of posterior dislocations

Reduction Techniques

Supine Technique

Place patient in supine position

An assistant stabilizes the humerus by wrapping both hands around arm just distal to axilla

The physician grasps the wrist with one hand and places the other hand just above the antecubital fossa with the thumb on the olecranon (FIGURE 65.3)

The physician applies slow, steady in-line traction while the assistant applies steady countertraction

To minimize additional trauma to the coronoid process, the elbow is held in slight flexion and the wrist is held in supination as traction is applied

Avoid hyperextension as this may cause injury to the median nerve or brachial artery

Reduction is accompanied by a “clunk” that is heard or felt

Alternatively, the forearm may be gently flexed in an effort to reduce the joint

Seated Technique

Patient is seated in a high backed chair with arm hanging over the back of the chair in a flexed position

The physician applies traction by gently pulling down on the patient’s hand while guiding the olecranon into place using the other hand

The physician may also elect to simply apply downward pressure onto the olecranon to reduce the elbow

Reduction is once again signaled by a “clunk”

This method has the advantage of requiring only a single physician

FIGURE 65.3 Technique for reduction of posterior dislocation of the elbow. (From Perron AD, Germann CA. Elbow injuries. In: Wolfson AB. Harwood-Nuss’ Clinical Practice of Emergency Medicine. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2015:260, with permission.)

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