01Approach to the Critical Patient/attcp56

Immediate priorities

›Neurovascular compromise triggers

›Absent or diminished radial or ulnar pulse

›Brachial artery injury occurs in 0.3–1.7% of elbow dislocations

›Emergent vascular surgery consultation

›CT angiography of the brachial artery if pulses present but asymmetric

›Vascular compromise signs

›Cyanosis, pallor, or cold hand

›Capillary refill >2 seconds distally

›Compartment syndrome threat

›Tense forearm compartments

›Pain with passive finger extension

›Pain out of proportion to injury

›Open dislocation

›Skin breach overlying joint

›Orthopedic surgery and operative intervention required

›Reduction urgency

›Closed reduction performed urgently to restore neurovascular flow

›Delays increase soft tissue swelling and complicate reduction

›Procedural sedation or intra-articular hematoma block

›Irreducible dislocation

›Suggests entrapped osteochondral fragment or radial head interposition

›Operative reduction required

›Do not apply excessive force

›Post-reduction neurovascular reassessment mandatory

›Repeat pulse check bilaterally

›Repeat neurologic exam of ulnar, median, radial, and AIN distributions

02History/hx56

Mechanism and presentation

›Core mechanism

›Fall on outstretched hand (FOOSH)

›Most common mechanism, approximately 42% of cases

›Hyperextension with valgus and axial load

›Sports-related injury

›Contact sports: football, wrestling, gymnastics

›High-energy collision mechanisms

›Motor vehicle collision

›Associated with complex dislocations

›Higher rate of vascular injury

›Injury timing

›Time since injury

›Delays >3 weeks classified as persistent dislocation

›Persistent dislocations carry worse functional outcomes

›Ability to move elbow or hand since injury

›Complete loss of motion suggests significant injury

›Neurologic symptoms: numbness, tingling, weakness

Symptom characterization

›Pain location and severity

›Posterior elbow pain and deformity

›Olecranon prominence most obvious finding

›Ipsilateral wrist or forearm pain

›Essex-Lopresti injury concern

›DRUJ disruption

›Monteggia fracture-dislocation variant

›Neurologic symptoms

›Ulnar nerve distribution

03Physical Exam/exam45

Limb inspection and deformity

›Gross deformity assessment

›Olecranon prominence posteriorly

›Foreshortened forearm appearance

›Disruption of normal triangular relationship: medial epicondyle, lateral epicondyle, olecranon

›Swelling and ecchymosis

›Extent and distribution

›Rapid expansion suggests vascular injury

›Skin integrity

›Open wound overlying joint

›Puncture or laceration

Neurovascular exam

›Pre-reduction neurovascular assessment (mandatory before any reduction attempt)

›Vascular exam

›Radial pulse: presence, strength, and symmetry

›Ulnar pulse: presence and strength

›Capillary refill: normal < 2 seconds

›Hand temperature and color

›Neurologic exam

›Ulnar nerve: sensation small finger, finger abduction strength

›Median nerve: sensation thenar eminence, thumb opposition

›AIN: index DIP and thumb IP flexion ("OK" sign)

›Radial nerve and PIN: wrist extension and finger extension

›Post-reduction neurovascular reassessment (mandatory)

›Repeat full neurovascular exam

›Compare directly to pre-reduction findings

›New deficit after reduction suggests entrapment or stretch injury

04Differential Diagnosis/ddx40

Fractures and fracture-dislocations

›Supracondylar fracture

›ICD-10: S42.401A

›Especially common in children: can mimic dislocation clinically

›Differentiating clue: fat pad sign without obvious dislocation

›Terrible triad injury

›ICD-10: S53.004A with associated radial head and coronoid fractures

›Posterior dislocation + radial head fracture + coronoid fracture

›Critical to distinguish from simple dislocation: requires surgical management

›Monteggia fracture-dislocation

›ICD-10: S52.271A

›Proximal ulna fracture with radial head dislocation

›Radial head dislocation always accompanies ulna fracture in true Monteggia

›Essex-Lopresti injury

›ICD-10: S52.121A with interosseous membrane disruption

›Radial head fracture + interosseous membrane disruption + DRUJ injury

›Longitudinal forearm instability: missed with elbow-only imaging

Isolated fractures

›Radial head fracture

›ICD-10: S52.121A

›Limited supination and pronation

›Positive posterior fat pad sign

›No joint dislocation on imaging

›Olecranon fracture

›ICD-10: S52.001A

›Posterior elbow pain, inability to extend against resistance

›Disrupted extensor mechanism

05Laboratory Tests/lt26

Pre-sedation labs

›Routine labs for procedural sedation

›No routine laboratory testing required for healthy patients

›Hemodynamically stable with isolated injury

›Standard of care per most institutional procedural sedation protocols

›Individualized assessment for comorbid patients

›Elderly or anticoagulated patients: BMP and CBC

›Cardiac history: ECG prior to sedation

Vascular injury and surgical planning labs

›Labs for suspected vascular injury

›Complete blood count

›Baseline hemoglobin and hematocrit

›Thrombocytopenia screen

›Type and screen

›All patients with suspected arterial injury

›Pre-operative requirement

›Coagulation studies

›PT/INR and aPTT for anticoagulated patients

›Reversal planning if emergent surgery required

›Basic metabolic panel

›Renal function if contrast CT angiography planned

›Electrolytes baseline

Open dislocation labs

›Labs for open dislocation requiring operative management

›CBC, BMP, type and screen

›Pre-operative baseline

›Blood cultures

›If signs of systemic infection

06Diagnostic Tests/dt69

Scoring Systems

›Mayo Elbow Performance Score (MEPS)

›Domains: pain, range of motion, stability, function

›Maximum 100 points

›Excellent: 90–100, Good: 75–89, Fair: 60–74, Poor: <60

›Use: outcome assessment at follow-up, not acute decision-making

›Baseline score in ED not routinely required

›Validated for tracking functional recovery

›Elbow instability classification

›Simple vs. complex dislocation

›Simple: no associated fracture (~42% of trauma center cases)

›Complex: associated fracture (~58% of trauma center cases, referral bias)

›Terrible triad grading

›Radial head fracture classification (Mason I/II/III)

›Coronoid fracture classification (Regan-Morrey I/II/III)

MRI

›MRI elbow indications

›Subacute ligamentous injury assessment

›Not routinely indicated in acute ED setting

›Appropriate for chronic instability evaluation after acute phase resolves

›Collateral ligament evaluation

›Lateral collateral ligament complex (LCLC) injury in virtually all posterolateral dislocations

›LCL complete rupture in approximately 88% of posterolateral dislocations

›Medial collateral ligament (MCL) injury variable

›Osteochondral lesion detection

›Subchondral injury missed on radiograph and CT

›Chondral defects relevant to long-term outcomes

›MRI protocol considerations

›Dedicated elbow coil

›High-resolution sequences: PD fat-sat, T2, T1

›Patient positioning: arm overhead or at side (hummingbird vs. standard)

›Contraindications

›Metallic hardware from prior fixation

›Pacemaker or implantable device

CT

›CT elbow without contrast

›Indications

›Fracture suspected but radiographs normal or indeterminate

›Characterize fracture morphology for surgical planning

›Post-reduction assessment of concentric reduction if unclear on radiograph

›Diagnostic performance

›Plain radiograph sensitivity for fractures in elbow dislocations: only 62%

›CT detects small fractures and impaction injuries present in up to 96% of cases even when radiographs appear normal

›CT identifies occult fractures that change management in a significant proportion

›Protocol

›Thin-slice axial acquisition with coronal and sagittal reconstructions

›No contrast required for fracture assessment

›CT angiography (CTA)

›Indications

›Absent or asymmetric pulses post-reduction

›Expanding hematoma or vascular bruit

›Concern for brachial artery injury

›Brachial artery injury

›Occurs in 0.3–1.7% of elbow dislocations

›CTA defines injury anatomy for surgical or endovascular planning

›ACR Appropriateness Criteria (2024)

›CTA appropriate for suspected vascular injury with elbow dislocation

Ultrasound

›Point-of-care ultrasound (POCUS)

›Joint effusion confirmation

›Posterior recess visualization: fluid in olecranon fossa

›Supports diagnosis of intra-articular pathology

›Reduction confirmation

›Dynamic assessment of radiocapitellar and ulnohumeral articulation

›Useful when fluoroscopy not available for real-time reduction guidance

›Vascular assessment

›Brachial artery Doppler

›Radial and ulnar artery waveform assessment

›Absence of flow or dampened waveform triggers CTA

›Compartment pressure measurement

›Not ultrasound-based: invasive needle manometry

›Stryker device or arterial line transducer technique

›Threshold: pressure within 30 mmHg of diastolic blood pressure

07Disposition/dispo44

Discharge criteria

›Criteria for safe discharge after ED management

›Successful closed reduction confirmed on post-reduction radiograph

›Concentric reduction of ulnohumeral and radiocapitellar joints

›No entrapped loose body

›Intact neurovascular exam post-reduction

›Radial and ulnar pulses present and symmetric

›No new neurologic deficit

›Stable joint through functional arc

›Elbow stable from 30–130 degrees flexion

›Simple dislocation without significant instability

›Posterior long-arm splint applied

›Elbow at 90 degrees flexion

›Forearm in neutral rotation

›Orthopedic follow-up arranged

›Within 5–7 days for stability reassessment

›Discharge instructions provided

Admission indications

›Criteria requiring admission or operative intervention

›Vascular injury

›Absent pulses requiring arterial repair or observation

›Vascular surgery consultation and OR planning

›Compartment syndrome

›Clinical diagnosis: fasciotomy required

›ICU or step-down monitoring post-operatively

›Open dislocation

›OR washout and closure

›Antibiotic prophylaxis initiated in ED

08Treatment/t91

Analgesia and procedural preparation

›Pain management

›Acetaminophen 1000 mg PO or IV

›First-line non-opioid analgesia

›Safe across age groups

›NSAIDs

›Ibuprofen 400–800 mg PO q6–8h

›Ketorolac 15–30 mg IV/IM for acute pain

›NSAIDs do not appear to have detrimental effect on soft tissue healing at low doses and short duration

›Caution: theoretical heterotopic ossification risk; indomethacin used prophylactically in high-risk cases

›Short-course opioids if needed

›Reserved for severe pain not controlled by non-opioids

›Avoid prolonged opioid prescriptions

›Procedural sedation options

›Propofol 1–2 mg/kg IV, titrate to effect

›Rapid onset, short duration

›Requires airway monitoring and capnography

›Ketamine 1–2 mg/kg IV or 4 mg/kg IM

›Dissociative sedation, maintains airway reflexes

›Useful for pediatric patients

›Consider midazolam 0.04–0.07 mg/kg IV pre-treatment for emergence phenomena in adults

›Midazolam 1–2 mg IV + fentanyl 1–2 mcg/kg IV

›Moderate sedation option

›Adequate for cooperative adult patients

›Intra-articular hematoma block

›Lidocaine 1% or 2% without epinephrine, 5–10 mL

›Inject into hematoma at lateral joint line

›Alternative or adjunct to procedural sedation

›Onset 5–10 minutes

Reduction techniques

›Traction-countertraction technique

›Setup

›Assistant stabilizes the humerus against the stretcher

›Operator applies longitudinal traction to the forearm

›Elbow slightly flexed during traction

›Steps

›Correct medial or lateral displacement first

›Apply steady longitudinal traction along the forearm axis

›Flex elbow while maintaining traction

›Palpable and audible "clunk" confirms reduction

›Leverage (modified Parvin) technique

›Patient position

›Supine

›Single operator

›Technique

›Forearm used as lever with olecranon as fulcrum

›Downward pressure on proximal forearm while elevating wrist

›Requires less force than traction-countertraction

›Modified Stimson technique

›Patient position

›Prone with arm hanging off the stretcher

›Downward traction on the wrist

›Technique

›Gravity-assisted distraction

›Gentle pressure on olecranon to guide reduction

›Suitable for cooperative patients

›General reduction principles

›No excessive force

›Resistance suggests entrapped fragment: stop and obtain imaging

›Palpable "clunk" confirms reduction

›Confirm with post-reduction radiograph

›Immediate post-reduction neurovascular reassessment mandatory

Post-reduction management

›Immobilization

›Posterior long-arm splint at 90 degrees elbow flexion

›Forearm in neutral rotation

›Duration: 7–14 days for simple dislocation

›Avoid prolonged immobilization (>2–3 weeks): strongly associated with worse outcomes

›Early mobilization protocol

›Early mobilization within 1–2 weeks is evidence-based standard

›Systematic review (Schubert et al., 2021): early mobilization 91% success vs. 79% prolonged immobilization

›ROM flexion-extension arc: 137 degrees (early mobilization) vs. 129–131 degrees (immobilization groups)

›Earlier return to work: approximately 3.2 weeks vs. 6.6 weeks

›Long-term outcomes excellent at 14–25 year follow-up with no late instability requiring surgery (Mackinnon et al., 2023)

›Physical therapy referral

›Guided ROM exercises: flexion-extension and pronation-supination

›Avoid forced passive extension and valgus stress during early healing

›Open dislocation management

›Antibiotic prophylaxis

›Cefazolin 1–2 g IV for non-penicillin-allergic patients

›Piperacillin-tazobactam 3.375 g IV q6h for heavily contaminated wounds

›Emergent OR for washout and wound management

›Surgical indications

›Irreducible dislocation

›Entrapped osteochondral fragment or soft tissue interposition

›Persistent instability post-reduction

›Redislocation at <30 degrees extension

›Primary ligament repair or reconstruction

›Complex fracture-dislocation with displaced fractures

›Radial head fixation or replacement

›Coronoid fracture fixation

›Collateral ligament repair

›Vascular injury

›Brachial artery repair or bypass

09Special Populations/sp79

Pregnancy

›Anatomic and physiologic considerations

›Imaging in pregnancy

›Plain radiographs: obtain with abdominal shielding

›CT: use only if clinically necessary; document radiation exposure discussion

›MRI: preferred over CT for non-urgent advanced imaging; no ionizing radiation

›Procedural sedation in pregnancy

›Propofol: Category B; short duration considered acceptable

›Ketamine: avoid in late pregnancy due to increased uterine tone risk

›Benzodiazepines: Category D; avoid if possible; neonatal effects with repeated exposure

›Medication safety

›Acetaminophen: first-line analgesic in pregnancy

›Standard dosing 1000 mg PO q6–8h

›NSAIDs: avoid after 20 weeks gestation

›Risk of premature ductus arteriosus closure

›Risk of oligohydramnios

›Opioids: short course acceptable for acute pain control

›Counsel on neonatal opioid withdrawal risk

›Minimize duration

›Fetal monitoring

›Continuous fetal heart rate monitoring if >20 weeks gestation during procedural sedation

›Obstetrics consultation for procedural sedation in second/third trimester

›Post-procedure fetal assessment

Geriatric

›Age-related considerations

›Osteoporosis and fracture risk

›Higher likelihood of associated fracture with dislocation

›Complex dislocation more common in elderly

›DEXA scan referral at follow-up if not previously assessed

›Ligamentous laxity reduction with age

›Fibrous tissue less compliant

›Greater force required leading to more energy transfer to bone

›Procedural sedation modifications

›Reduced medication doses

›Propofol: start 0.5–1 mg/kg IV; titrate slowly

›Ketamine: 0.5–1 mg/kg IV; emergence phenomena management

›Fentanyl: 0.5–1 mcg/kg IV; age-associated sensitivity

›Respiratory monitoring

›Increased aspiration risk in frail elderly

›Capnography mandatory

›Preoperative NPO status verification

›Post-reduction considerations

›Higher risk of posttraumatic stiffness

›Early mobilization especially important in elderly

›Physical therapy initiation within 1–2 weeks

›Medication management

›NSAIDs with caution: renal impairment and GI risk

›Prefer acetaminophen as primary analgesic

›Avoid long-acting opioids

Pediatrics

›Age-specific anatomy and injury patterns

›Ossification centers (CRITOE mnemonic)

›Capitellum: appears age 1

›Radial head: appears age 3

›Internal (medial) epicondyle: appears age 5

›Trochlea: appears age 7

›Olecranon: appears age 9

›External (lateral) epicondyle: appears age 11

›Medial epicondyle avulsion common with elbow dislocation in children

›Nursemaid's elbow distinction

›Age <5 years: radial head subluxation, not true dislocation

›Reduction: supination-flexion or hyperpronation technique

›Hyperpronation technique: higher first-attempt success rate (>90%)

›Non-accidental trauma

›Mechanism inconsistent with age or injury pattern

›Bilateral injuries or multiple fractures at different healing stages

›Mandatory reporting if suspected

›Child protective services notification

›Procedural sedation in children

›Ketamine 1–2 mg/kg IV or 4 mg/kg IM

›Preferred agent for pediatric procedural sedation for orthopedic injuries

›Maintain airway reflexes

›Atropine 0.01 mg/kg IV may reduce secretions (minimum 0.1 mg)

›Weight-based dosing mandatory

›Fentanyl 1–2 mcg/kg IV

›Midazolam 0.05–0.1 mg/kg IV

›Post-reduction in pediatrics

›Comparison views

›Contralateral elbow radiograph for ossification center comparison if diagnosis uncertain

›Immobilization

›Posterior long-arm splint at 90 degrees

›Orthopedic follow-up within 5–7 days

10Background/b82

Epidemiology

›Incidence and demographics

›Frequency

›Second most common large joint dislocation after shoulder

›Incidence approximately 5–6 per 100,000 persons per year

›Age distribution

›Peak incidence in second decade of life (10–20 years)

›Adults: average age approximately 48 years in trauma center series

›Sex distribution

›Male predominance: approximately 1.9:1 male-to-female ratio

›Dislocation subtypes

›Direction of dislocation

›Posterior and posterolateral: approximately 90% of all cases

›Anterior: rare, typically high-energy

›Medial and lateral: uncommon

›Simple vs. complex

›Simple (no fracture): approximately 42% of trauma center cases

›Complex (with fracture): approximately 58% of trauma center cases (referral bias)

›Terrible triad

›Posterior dislocation + radial head fracture + coronoid fracture

›Worst prognosis among elbow fracture-dislocations

Pathophysiology

›Ligamentous injury sequence

›Mechanism of posterolateral dislocation

›Hyperextension with valgus and axial load on FOOSH

›Lateral collateral ligament complex (LCLC) fails first

›LCL complete rupture in approximately 88% of posterolateral dislocations

›Progressive medial-to-lateral or lateral-to-medial soft tissue disruption

›MCL injury

›Variable degree of medial collateral ligament disruption

›Complete disruption associated with instability and recurrence

›Associated injuries

›Bony injuries

›Small fractures and impaction injuries in up to 96% on CT even when radiographs appear normal (Sormaala et al., 2014)

›Radial head fracture most common associated fracture

›Coronoid fracture: critical stabilizer against posterior subluxation

›Vascular injury

›Brachial artery injury: 0.3–1.7% incidence

›Anterior interosseous artery at risk with anterior dislocations

›Neurologic injury

›Ulnar nerve most commonly injured

›Median nerve second most common

›AIN neuropraxia may be subtle

›Late complications

›Posttraumatic stiffness: most common late complication

›Flexion contracture of 5–10 degrees common and usually well-tolerated

›Prolonged immobilization >2–3 weeks strongly associated with worse outcomes

›Posterolateral rotatory instability (PLRI)

›Insufficiency of lateral ulnar collateral ligament

›Late complication of inadequately treated LCLC disruption

›Heterotopic ossification

›Ectopic bone formation in periarticular soft tissues

›Risk increased with prolonged immobilization and high-energy injury

›Chronic pain and recurrent instability

›Rare after simple dislocation with appropriate management

Therapeutic Considerations

›Evidence base for early mobilization

›Systematic review (Schubert et al., 2021, Medicine)

›Early mobilization: 91% success rate vs. 79% for prolonged immobilization

›ROM arc: 137 degrees early mobilization vs. 129–131 degrees immobilization

›Return to work: 3.2 weeks vs. 6.6 weeks

›Long-term follow-up (Mackinnon et al., 2023, JBJS)

›14–25 year follow-up after closed reduction and early movement

›Excellent outcomes with no late instability requiring surgery

›Cochrane Review (Taylor et al., 2012)

›Insufficient evidence to determine superiority of any single reduction technique

›Early mobilization consistently associated with better outcomes

›Reduction technique evidence

›All standard techniques (traction-countertraction, leverage, Stimson) are acceptable

›No single technique proven superior in controlled trials

›Choice based on operator experience and patient cooperation

›Hematoma block as alternative to procedural sedation

›Reduces systemic medication exposure

›Adequate analgesia for cooperative patients

›Surgical vs. conservative management

›Simple dislocation: conservative management with early mobilization is standard

›Surgical repair reserved for persistent instability or irreducible cases

›Complex dislocation: operative management typically required

›Radial head fixation or arthroplasty

›Coronoid fracture fixation

›LCL repair or reconstruction

›ACR Appropriateness Criteria (2024)

›Plain radiographs usually sufficient for acute presentation

›CT appropriate for complex injury characterization

›MRI appropriate for subacute ligament evaluation

11Patient Discharge Instructions/pdi47

copy discharge instructions

›Diagnosis and what happened

›Elbow dislocation: the bones of your elbow joint were displaced from their normal position

›Your elbow has been successfully put back into place (reduced)

›X-rays confirmed proper alignment after reduction

›Your arm is in a splint

›Keep the splint on at all times unless instructed otherwise

›Keep your arm elevated above heart level to reduce swelling

›Activity restrictions

›No lifting, pushing, or pulling with the injured arm

›Until cleared by your orthopedic surgeon

›No driving until cleared

›Narcotic pain medications also impair driving

›Avoid sports and contact activities

›Until ligament healing confirmed by follow-up exam

›Pain management at home

›Acetaminophen (Tylenol) 500–1000 mg every 6–8 hours as needed

›Do not exceed 4000 mg in 24 hours

›Do not take with other acetaminophen-containing products

›Ibuprofen (Advil/Motrin) 400–600 mg every 6–8 hours with food

›Take with food to reduce stomach upset

›Avoid if kidney disease, ulcers, or aspirin allergy

›Ice pack to elbow for 15–20 minutes several times daily

›Wrap ice in cloth: do not apply directly to skin

›Follow-up instructions

›Orthopedic surgery follow-up within 5–7 days

›Stability reassessment and rehabilitation planning

›Do not miss this appointment: instability can develop

12References/r46

Guidelines and key sources

›Schubert I, Strohm PC, Maier D, Zwingmann J

›Simple Traumatic Elbow Dislocations; Benefit From Early Functional Rehabilitation: A Systematic Review With Meta-Analysis Including PRISMA Criteria

›Medicine 2021

›PubMed: 34871203

›Hackl M, Beyer F, Wegmann K, et al

›The Treatment of Simple Elbow Dislocation in Adults

›Deutsches Arzteblatt International 2015

›PubMed: 26037467

›Gottlieb M, Schiebout J

›Elbow Dislocations in the Emergency Department: A Review of Reduction Techniques

›Journal of Emergency Medicine 2018

›PubMed: 29681420

›Lee SH, Nam DJ, Yu HK, Kim JW

›The Lateral Ligament Is Injured Preferentially in Posterolateral Dislocation of the Elbow Joint

›Bone and Joint Journal 2020

›PubMed: 32009431

›Carter SJ, Germann CA, Dacus AA, Sweeney TW, Perron AD

›Orthopedic Pitfalls in the ED: Neurovascular Injury Associated With Posterior Elbow Dislocations

›American Journal of Emergency Medicine 2010

›PubMed: 20887916

›Pott CMJM, de Klerk HH, Priester-Vink S, Eygendaal D, van den Bekerom MPJ

›Treatment Outcomes of Simple Elbow Dislocations: A Systematic Review of 1,081 Cases

›JBJS Reviews 2024

›PubMed: 38181107

›Chen KC, Ha AS, Bartolotta RJ, et al

›ACR Appropriateness Criteria: Acute Elbow and Forearm Pain

›Journal of the American College of Radiology 2024

Evidence & Review

Evidence & Review