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
Background
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
Patient Discharge Instructions
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
Physical therapy referral will be arranged at follow-up
Early motion exercises are important to prevent stiffness
Return to emergency department immediately for
Vascular warning signs
Hand or fingers turning pale, blue, or cold
Loss of pulse sensation in wrist
Severe swelling of hand or forearm
Neurologic warning signs
Increasing numbness or tingling in fingers
Inability to move fingers
New weakness of hand grip
Compartment syndrome warning signs
Worsening pain despite pain medications
Pain when straightening fingers passively
Tight or "bursting" sensation in forearm
Infection warning signs (if open wound)
Increasing redness, warmth, or discharge from wound
Fever above 38.5 degrees Celsius
Elbow re-dislocation
Sudden shift or pop with deformity returning
References
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
Mackinnon T, Samuel TD, Hayter E, et al
Long-Term Follow-Up (14 to 25 Years) Following Closed Reduction and Early Movement for Simple Dislocation of the Elbow
Journal of Bone and Joint Surgery American Volume 2023
PubMed: 37616331
Sormaala MJ, Sormaala A, Mattila VM, Koskinen SK
MDCT Findings After Elbow Dislocation: A Retrospective Study of 140 Patients
Skeletal Radiology 2014
PubMed: 24453027
Taylor F, Sims M, Theis JC, Herbison GP
Interventions for Treating Acute Elbow Dislocations in Adults
Cochrane Database of Systematic Reviews 2012
Gottlieb M, Suleiman LI
Current Approach to the Management of Forearm and Elbow Dislocations in Children
Pediatric Emergency Care 2019
PubMed: 30921172
Breulmann FL, Lappen S, Ehmann Y, et al
Treatment Strategies for Simple Elbow Dislocation: A Systematic Review
BMC Musculoskeletal Disorders 2024
PubMed: 38365699
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