The second most common large joint dislocation (after shoulder), with an incidence of approximately 5–6 per 100,000 persons per year. [1-2] Posterior/posterolateral dislocations account for the vast majority of cases. [3-4] Classified as simple (no associated fracture) or complex (with fracture). Requires urgent reduction and careful neurovascular assessment.
1. History
- Mechanism of injury: Fall on an outstretched hand (FOOSH) is the most common mechanism (~42%), followed by sports injuries and motor vehicle collisions [5-6]
- Characterize the force vector: hyperextension with valgus/axial load is the classic mechanism for posterior dislocation
- Timing: when did the injury occur? Delays >3 weeks are classified as "persistent" dislocations and carry worse outcomes [7]
- Prior dislocations or elbow instability episodes
- Hand dominance and occupation/sport
- Ability to move the elbow or hand since injury — assess for neurologic symptoms (numbness, tingling, weakness in ulnar/median nerve distributions)
- Important negatives: open wound (open dislocation), forearm/wrist pain (Essex-Lopresti or DRUJ injury)
2. Alarm Features
- Absent or diminished distal pulses — brachial artery injury occurs in 0.3–1.7% of elbow dislocations [8]
- Cyanosis, pallor, or cold hand — vascular compromise
- Compartment syndrome: tense forearm, pain with passive finger extension, pain out of proportion
- Open dislocation (skin breach)
- Neurologic deficit (ulnar nerve most commonly injured, followed by median nerve) [6]
- Irreducible dislocation — suggests entrapped fragment or radial head interposition [9]
- Associated fracture converting simple to complex dislocation (terrible triad: posterior dislocation + radial head fracture + coronoid fracture) [10]
3. Medications
- Procedural sedation agents for reduction: propofol, ketamine, midazolam/fentanyl per institutional protocol
- Intra-articular lidocaine (hematoma block) can be used as an alternative or adjunct
- Post-reduction analgesia: acetaminophen, NSAIDs (first-line); short-course opioids if needed
- NSAIDs do not appear to have a detrimental effect on soft tissue healing at low doses and short duration [11]
- Avoid prolonged opioid prescriptions
- Caution: some literature suggests NSAIDs may theoretically increase heterotopic ossification risk, though evidence is mixed; indomethacin has been used prophylactically in high-risk cases
4. Diet
- No specific acute dietary considerations
- Adequate calcium and vitamin D intake for bone healing if associated fracture
- Maintain hydration, especially if procedural sedation is planned (NPO considerations)
5. Review of Systems
- Neurologic: numbness/tingling in hand (ulnar nerve — ring/small finger; median nerve — thumb/index/middle; anterior interosseous nerve — inability to make "OK" sign)
- Vascular: hand color, temperature, capillary refill
- Musculoskeletal: ipsilateral wrist/forearm pain (rule out Essex-Lopresti, Monteggia variant, DRUJ disruption) [12]
- Cervical spine or shoulder symptoms if high-energy mechanism
- Skin integrity (open vs. closed injury)
6. Collateral History and Family History
- Witnesses to mechanism (especially in sports or pediatric patients)
- In children: consider non-accidental trauma if mechanism is inconsistent with injury pattern
- History of connective tissue disorders or generalized ligamentous laxity (Ehlers-Danlos, Marfan) — predisposes to recurrent instability
- Family history of hypermobility syndromes
7. Risk Factors
- Age: peak incidence in the second decade of life (10–20 years); adults average age ~48 years in trauma center series [5]
- Male predominance (~1.9:1 male-to-female ratio) [5]
- Contact sports (football, wrestling, gymnastics)
- Falls from height or high-energy trauma (associated with complex dislocations and vascular injury)
- Generalized ligamentous laxity
- Prior elbow dislocation or instability
8. Differential Diagnosis
- Supracondylar fracture (especially in children — can mimic dislocation clinically)
- Radial head fracture (isolated — limited supination/pronation, positive fat pad sign)
- Olecranon fracture (posterior elbow pain, inability to extend)
- Terrible triad injury (dislocation + radial head fracture + coronoid fracture) — a complex dislocation, not a separate entity but critical to distinguish from simple dislocation [10]
- Monteggia fracture-dislocation (proximal ulna fracture + radial head dislocation) [13]
- Essex-Lopresti injury (radial head fracture + interosseous membrane disruption + DRUJ injury)
- Nursemaid's elbow (radial head subluxation in children <5 years — distinct from true dislocation) [14]
- Septic joint (atraumatic, febrile — rare mimic)
9. Past Medical History
- Prior elbow dislocations or subluxations
- Previous elbow surgery or fractures
- Connective tissue disorders (Ehlers-Danlos, Marfan)
- Osteoporosis or metabolic bone disease (increases fracture risk with dislocation)
- Anticoagulant use (increases bleeding/hematoma risk)
- Chronic elbow conditions (arthritis, heterotopic ossification)
10. Physical Exam
- Inspection: obvious deformity — olecranon prominence posteriorly, foreshortened forearm; significant swelling and ecchymosis
- Neurovascular exam before AND after reduction — this is critical: [6]
- Radial and ulnar pulses, capillary refill
- Ulnar nerve: sensation over small finger, finger abduction strength
- Median nerve: sensation over thenar eminence, thumb opposition
- Anterior interosseous nerve: flexion of DIP of index finger and IP of thumb ("OK" sign)
- Radial nerve/PIN: wrist and finger extension
- Post-reduction stability testing: gently assess varus/valgus stress and determine the angle at which the elbow redislocates in extension — if stable through a functional arc (30–130°), conservative management is appropriate [12]
- Assess forearm compartments for tautness (compartment syndrome)
- Examine ipsilateral wrist for DRUJ tenderness [12]
11. Lab Studies
- Labs are generally not required for isolated simple elbow dislocation
- If procedural sedation is planned: no routine labs needed for healthy patients per most institutional protocols
- If vascular injury suspected: type and screen, CBC, coagulation studies
- If open dislocation or surgical intervention planned: CBC, BMP, type and screen
12. Imaging
- First-line: AP and lateral radiographs of the elbow — confirm direction of dislocation, identify associated fractures [13]
- Posterior fat pad sign suggests occult fracture
- Assess for radial head, coronoid, and epicondyle fractures
- Post-reduction radiographs: mandatory to confirm concentric reduction and identify fractures that may have been obscured pre-reduction [13]
- CT without contrast: indicated when fracture is suspected but radiographs are normal/indeterminate, or to characterize fracture morphology for surgical planning. CT detects fractures missed on radiographs — radiograph sensitivity for fractures in elbow dislocations is only 62% [13][15]
- MRI: not routinely indicated acutely; may be useful for ligamentous injury assessment in subacute setting [13]
- CT angiography: if vascular injury is suspected (absent pulses, expanding hematoma) [6]
13. Special Tests
- Post-reduction stability exam: the most important "special test" — assess the angle of extension at which the elbow redislocates under gravity with the forearm in pronation (pronation tightens the lateral collateral ligament complex)
- Elbow extension test: inability to fully extend the elbow while seated with shoulders at 90° flexion suggests occult fracture [13]
- Mayo Elbow Performance Score (MEPS): used for outcome assessment, not acute decision-making [16]
- Point-of-care ultrasound: can confirm joint effusion and may assist in confirming reduction
- Compartment pressure measurement: if compartment syndrome is suspected clinically
14. ECG
- Not routinely indicated for isolated elbow dislocation
- Obtain if procedural sedation is planned in patients with cardiac history or risk factors, per institutional sedation protocols
- No specific ECG findings associated with elbow dislocation
15. Assessment
Elbow dislocations are classified as:
- Simple: dislocation without fracture — ~42% of cases in trauma center series [5]
- Complex: dislocation with associated fracture — ~58% in trauma center data, though this is skewed by referral bias [5]
Posterior/posterolateral is the most common direction (~90%). The lateral collateral ligament (LCL) is injured in virtually all posterolateral dislocations (complete rupture in ~88%), while medial collateral ligament (MCL) injury varies. [4] Small fractures and impaction injuries are present in up to 96% of cases on CT, even when radiographs appear normal. [15] Late complications include posttraumatic stiffness (most common), posterolateral rotatory instability, ectopic ossification, and chronic pain. [12][17]
16. Treatment Plan
Initial stabilization
- Neurovascular assessment, splint in position of comfort if reduction is delayed
- Procedural sedation or hematoma block
Reduction techniques: [3][18-19]
- Traction-countertraction: assistant stabilizes the humerus; operator applies longitudinal traction to the forearm with the elbow slightly flexed, correcting medial/lateral displacement, then flexing the elbow
- Leverage technique: performed supine, single operator; forearm is used as a lever with the olecranon as a fulcrum — requires less force
- Modified Stimson technique: patient prone with arm hanging off the bed; downward traction on the wrist with gentle pressure on the olecranon
- A palpable "clunk" confirms reduction
Post-reduction
- Repeat neurovascular exam [6]
- Assess stability through range of motion — determine the angle at which redislocation occurs
- Post-reduction radiographs to confirm concentric reduction [13]
- Immobilization: posterior long-arm splint at 90° flexion for 7–14 days [9]
- Early mobilization (within 1–2 weeks) is the evidence-based standard and produces superior outcomes compared to prolonged immobilization (>3 weeks): [1-2][7][16][20]
- Early mobilization group: 91% success rate vs. 79% for prolonged immobilization [1]
- ROM flexion-extension arc: 137° (early mobilization) vs. 129–131° (immobilization groups) [7]
- Earlier return to work (~3.2 weeks vs. 6.6 weeks) [21]
- Long-term outcomes with early mobilization protocol remain excellent at 14–25 years follow-up with no late instability requiring surgery [20]
Surgical indications: [5][16]
- Irreducible dislocation (entrapped fragment)
- Persistent instability after reduction (redislocation at <30° extension)
- Complex dislocation with displaced fractures requiring fixation
- Severe bilateral ligament injuries with moderate-to-severe instability
17. Disposition
- Discharge: most simple elbow dislocations after successful closed reduction with confirmed concentric reduction, intact neurovascular exam, and stable joint [12]
- Admission/observation criteria:
- Vascular injury requiring repair or observation
- Compartment syndrome or concern for evolving compartment syndrome
- Open dislocation
- Complex fracture-dislocation requiring operative planning
- Irreducible dislocation requiring OR
- Failed reduction in ED
- Orthopedic consultation in ED: complex dislocations, neurovascular compromise, irreducible dislocations, significant instability
- Outpatient orthopedic follow-up: all first-time simple dislocations within 5–7 days for stability reassessment and initiation of rehabilitation
18. Follow Up / Return Precautions
- Follow-up: orthopedic follow-up within 5–7 days; reassess stability, review imaging, begin early ROM exercises
- Physical therapy referral for guided rehabilitation — focus on restoring flexion-extension and pronation-supination [9][16]
- Avoid forced passive extension and valgus stress during early healing
Return precautions — instruct patients to return immediately for:
- Increasing numbness, tingling, or weakness in the hand/fingers
- Hand turning pale, blue, or cold
- Worsening pain despite medications, especially pain with passive finger extension (compartment syndrome)
- Inability to move fingers
- Fever or signs of infection (if open wound)
Expected recovery
- Most patients achieve functional ROM by 3–6 months
- Mild flexion contracture (5–10°) is common and usually well-tolerated
- Prolonged immobilization (>2–3 weeks) is strongly associated with worse outcomes and should be avoided [1-2][17]
- Recurrent instability after simple dislocation is rare with appropriate management [20]
References
1. Simple Traumatic Elbow Dislocations; Benefit From Early Functional Rehabilitation: A Systematic Review With Meta-Analysis Including PRISMA Criteria. — Schubert I, Strohm PC, Maier D, Zwingmann J. Medicine. 2021.
2. The Treatment of Simple Elbow Dislocation in Adults. — Hackl M, Beyer F, Wegmann K, et al. Deutsches Arzteblatt International. 2015.
3. Elbow Dislocations in the Emergency Department: A Review of Reduction Techniques. — Gottlieb M, Schiebout J. The Journal of Emergency Medicine. 2018.
4. The Lateral Ligament Is Injured Preferentially in Posterolateral Dislocation of the Elbow Joint. — Lee SH, Nam DJ, Yu HK, Kim JW. The Bone & Joint Journal. 2020.
5. Epidemiology and Treatment of Acute Elbow Dislocations: Current Concept Based on Primary Surgical Ligament Repair of Unstable Simple Elbow Dislocations. — Mühlenfeld N, Frank J, Lustenberger T, Marzi I, Sander AL. European Journal of Trauma and Emergency Surgery : Official Publication of the European Trauma Society. 2022.
6. Orthopedic Pitfalls in the ED: Neurovascular Injury Associated With Posterior Elbow Dislocations. — Carter SJ, Germann CA, Dacus AA, Sweeney TW, Perron AD. The American Journal of Emergency Medicine. 2010.
7. Treatment Outcomes of Simple Elbow Dislocations: A Systematic Review of 1,081 Cases. — Pott CMJM, de Klerk HH, Priester-Vink S, Eygendaal D, van den Bekerom MPJ. JBJS Reviews. 2024.
8. Acute Elbow Dislocation With Arterial Rupture. Analysis of Nine Cases. — Ayel JE, Bonnevialle N, Lafosse JM, et al. Orthopaedics & Traumatology, Surgery & Research : OTSR. 2009.
9. Interventions for Treating Acute Elbow Dislocations in Adults. — Taylor F, Sims M, Theis JC, Herbison GP. The Cochrane Database of Systematic Reviews. 2012.
10. The Radiological Findings in Complex Elbow Fracture-Dislocation Injuries. — Al-Ani Z, Tham JL, Ooi MWX, et al. Skeletal Radiology. 2022.
11. Initial Assessment and Management of Select Musculoskeletal Injuries: A Team Physician Consensus Statement. — Herring SA, Kibler WB, Putukian M, et al. Medicine and Science in Sports and Exercise. 2024.
12. Acute Elbow Dislocation: Evaluation and Management. — Cohen MS, Hastings H. The Journal of the American Academy of Orthopaedic Surgeons. 1998.
13. ACR Appropriateness Criteria® Acute Elbow and Forearm Pain. — Chen KC, Ha AS, Bartolotta RJ, et al. Journal of the American College of Radiology : JACR. 2024.
14. Current Approach to the Management of Forearm and Elbow Dislocations in Children. — Gottlieb M, Suleiman LI. Pediatric Emergency Care. 2019.
15. MDCT Findings After Elbow Dislocation: A Retrospective Study of 140 Patients. — Sormaala MJ, Sormaala A, Mattila VM, Koskinen SK. Skeletal Radiology. 2014.
16. Treatment Strategies for Simple Elbow Dislocation - A Systematic Review. — Breulmann FL, Lappen S, Ehmann Y, et al. BMC Musculoskeletal Disorders. 2024.
17. Simple Dislocation of the Elbow in the Adult. Results After Closed Treatment. — Mehlhoff TL, Noble PC, Bennett JB, Tullos HS. The Journal of Bone and Joint Surgery. American Volume. 1988.
18. A Novel Reduction Technique for Elbow Dislocations. — Skelley NW, Chamberlain A. Orthopedics. 2015.
19. Posterior Dislocation of the Elbow. A Simplified Method of Closed Reduction. — Hankin FM. Clinical Orthopaedics and Related Research. 1984.
20. Long-Term Follow-Up (14 to 25 Years) Following Closed Reduction and Early Movement for Simple Dislocation of the Elbow. — Mackinnon T, Samuel TD, Hayter E, et al. The Journal of Bone and Joint Surgery. American Volume. 2023.
21. Simple Elbow Dislocation Among Adults: A Comparative Study of Two Different Methods of Treatment. — Maripuri SN, Debnath UK, Rao P, Mohanty K. Injury. 2007.