Elbow Dislocation and Reduction

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

   imagesThe clinical presentation depends on the type of dislocation

   imagesSuspected 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

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


imagesOpen dislocations require emergent consultations with an orthopedic surgeon

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

imagesIrreducible elbow dislocations may require operative management

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


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

imagesSoft-tissue injury may occur with reduction attempts

imagesFractures and neurovascular injury may occur with reduction attempts

imagesGeneral Basic Steps

   imagesObtain necessary x-rays


   imagesPosition patient


   imagesPostprocedure 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.)


imagesPerform a complete neurovascular check before any reduction attempt

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

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

   imagesDislocations with neurovascular compromise should be reduced without prior imaging

imagesAnesthesia/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

imagesReduction technique is determined by the type of dislocation


images80% to 90% of all elbow dislocations

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

imagesClinical 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).

imagesAssociated injuries:

   imagesFractures including radial head and coronoid process are common

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

   imagesNeurologic symptoms accompany 15% to 22% of dislocations

      imagesUlnar nerve injury is most common followed by median nerve injury

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

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

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

imagesReduction Techniques

   imagesSupine Technique

      imagesPlace patient in supine position

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

      imagesThe 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)

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

      imagesTo 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

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

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

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

   imagesSeated Technique

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

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

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

      imagesReduction is once again signaled by a “clunk”

      imagesThis 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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Aug 9, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Elbow Dislocation and Reduction
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