Elbow dislocations are the second most common major joint dislocation and usually occur posteriorly, although they can be anterior, medial, or lateral. All require immediate reduction to relieve pain and prevent neurovascular compromise. Brachial artery function and ulnar, median, and radial nerve integrity must be evaluated. Elbow dislocations are often associated with a radial head fracture. Patients with posterior dislocations present with their elbow held in flexion and a swollen, tender, and deformed elbow with a prominent olecranon. Anterior dislocations, although rare, present with the elbow extended with the forearm supinated and elongated. Radiographs should include an AP and a lateral view. The presence of fractures should be noted, as this may complicate reduction.
Management and Disposition
Most patients require conscious sedation prior to reduction. Posterior dislocations are accomplished by applying posterior pressure to the humerus while an assistant applies longitudinal forearm traction. Alternatively, the patient is placed in the prone position so the humerus hangs perpendicular to the stretcher. A 5- to 10-lb weight is applied to the wrist or axial traction is applied to the wrist while the elbow at the humerus is stabilized. After a few minutes, the olecranon slips back into place. During reduction, the nerve may become entrapped, so neurovascular integrity must be checked before and after reduction. If this occurs, orthopedics should be consulted immediately. After successful reduction, the elbow should be immobilized in 90 degrees of flexion in a posterior splint and sling. Associated fractures may make closed reduction difficult and leave the joint unstable. In these cases, orthopedic consultation is recommended prior to reduction.
Posterior Elbow Dislocation. This patient dislocated his elbow while playing basketball. Note the flexed position and the prominence of the olecranon. (Photo contributor: Frank Birinyi, MD.)
Posterior Elbow Dislocation. Lateral radiograph demonstrating posterior elbow dislocation. (Photo contributor: Selim Suner, MD, MS.)
The ulnar nerve is the most common nerve injured.
The olecranon should form a straight line with the two epicondyles when the elbow is extended. At 90 degrees of flexion, the olecranon and the two epicondyles should form a triangle. This relationship is disrupted in the dislocated elbow.
If there is concern for a possible fracture, consider obtaining a CT scan after reduction is performed.