Reduction and immobilization
›Closed reduction strategy
›Indications
›Posterior elbow dislocation without fracture block
›Vascular compromise requiring urgent realignment
›Contraindications to ED reduction
›Open fracture dislocation without immediate operative support
›Irreducible dislocation with suspected incarcerated fragment
›Technique options
›Prone technique
›Arm hanging with gravity assistance
›Downward traction then olecranon guidance
›Supine traction countertraction
›Longitudinal traction on forearm
›Countertraction on humerus
›Gentle flexion with pressure on olecranon
›Post-reduction checks
›Immediate neurovascular reassessment
›Post-reduction X-ray
›Gentle stability assessment in flexion only
›Immobilization plan
›Posterior long arm splint
›Elbow flexion target 90 degrees if stable perfusion and nerve exam
›Forearm position guided by stability
›Duration minimization
›Simple stable dislocation, brief immobilization then early range of motion
›Prolonged immobilization risk for stiffness and loss of extension
Analgesia and procedural sedation
›Multimodal analgesia
›Non-opioid base
›Paracetamol
›Adult oral 1000 mg every 6 hours
›Maximum 4000 mg per 24 hours
›Ibuprofen
›Adult oral 400 to 600 mg every 6 to 8 hours
›Contraindications renal disease, GI bleeding risk, pregnancy third trimester
›Opioid for severe pain
›Morphine IV
›Adult 0.05 to 0.1 mg/kg IV
›Titrate every 5 to 10 minutes to analgesia and respiratory safety
›Hydromorphone IV
›Adult 0.2 to 0.5 mg IV
›Repeat every 10 to 15 minutes as needed
›Procedural sedation options
›Ketamine
›Adult IV 1 to 2 mg/kg
›Onset minutes
›Additional 0.5 mg/kg as needed
›Pediatric IV 1 to 2 mg/kg
›Additional 0.5 to 1 mg/kg as needed
›Propofol
›Adult IV 0.5 to 1 mg/kg initial
›Additional 0.25 to 0.5 mg/kg every 1 to 3 minutes
›Hypotension and apnea monitoring
›Etomidate
›Adult IV 0.1 to 0.2 mg/kg
›Short duration for quick reduction
›Myoclonus consideration
›Nitrous oxide where available
›Simple dislocation reduction adjunct
›Avoid in pneumothorax risk and inability to protect airway
Regional anesthesia options
›Peripheral nerve blocks if expertise available
›Supraclavicular or infraclavicular brachial plexus block
›Ultrasound guidance for safety
›Local anesthetic dosing per institutional maximum mg/kg
›Axillary block for distal arm and forearm analgesia
›Median ulnar radial coverage planning
›Local anesthetic joint injection option
›Intra-articular lidocaine for selected simple dislocation
›Sterile technique requirement
›Avoid if open injury or septic concern
Open injury and infection prophylaxis
›Antibiotics for open fracture dislocation
›First generation cephalosporin
›Cefazolin IV 2 g
›Repeat every 8 hours
›Higher dose strategy in obesity per protocol
›Soil or farm contamination
›Add anaerobe coverage
›Metronidazole IV 500 mg every 8 hours
›Severe beta-lactam allergy
›Clindamycin IV 900 mg every 8 hours
›Tetanus prophylaxis
›Vaccination status assessment
›Booster if not up to date
›Tetanus immune globulin for high-risk wounds and incomplete series
Evidence and guideline framing
›Early reduction for pulseless or poorly perfused extremity is Class I recommendation
›Goal restoration of perfusion before definitive imaging
›Post-reduction vascular reassessment determines next steps
›Early mobilization after stable simple dislocation is Class IIa recommendation
›Stiffness reduction benefit
›Short immobilization strategy
›Procedural sedation safety standards align with ACEP Level B recommendation
›Continuous monitoring requirements
›Dedicated clinician for sedation monitoring