Neurovascular exam normal or improving neuropraxia with plan
Pain controlled on oral regimen
Immobilization applied
Early orthopedic follow-up arranged
Follow-up timing targets
Simple dislocation
Orthopedic review within 3 to 7 days
Early motion plan to reduce stiffness
Suspected occult fracture
Repeat imaging plan within 7 to 10 days
Treatment
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
Special Populations
Pregnancy
Pregnancy considerations
Imaging strategy
X-ray acceptable with shielding when clinically needed
CT only when benefits outweigh risks
Medication considerations
Paracetamol preferred
NSAID avoidance in later pregnancy
Opioid short-course if needed
Positioning considerations
Left lateral tilt in late pregnancy during sedation
Geriatric
Older adult considerations
Fragility fracture likelihood
Distal humerus fracture higher prevalence
Osteoporosis context
Medication sensitivity
Lower initial opioid dosing
Higher delirium risk with sedatives
Functional needs
Baseline independence and mobility supports
Home safety planning for one-arm limitation
Pediatrics
Pediatric considerations
Common associated injuries
Medial epicondyle avulsion with dislocation
Supracondylar humerus fracture mimic
Neurovascular vigilance
Brachial artery compromise risk
Compartment syndrome risk
Immobilization and follow-up
Pediatric orthopedic follow-up within 24 to 72 hours for fracture suspicion
Growth plate injury consideration
Background
Epidemiology
Epidemiology
Elbow dislocation frequency
Second most common large-joint dislocation in adults
Posterior direction most common
Sports association
Contact sports and falls
High-energy trauma association for complex injuries
Pediatric pattern differences
Lower overall frequency than adult
Higher association with medial epicondyle injury
Pathophysiology
Mechanism and structures
Posterolateral rotatory mechanism
Lateral ulnar collateral ligament disruption
Sequential soft tissue failure pattern
Terrible triad concept
Elbow dislocation with radial head fracture and coronoid fracture
Instability and stiffness risk
Neurovascular injury mechanisms
Ulnar nerve stretch or contusion
Brachial artery traction or intimal injury
Therapeutic Considerations
Therapeutic principles
Concentric reduction priority
Restores anatomy and perfusion
Enables accurate fracture assessment
Stability guided immobilization and motion
Stable simple dislocation benefits from early motion
Unstable pattern requires orthopedic-directed splint position
Complication prevention
Stiffness mitigation with early supervised range
Heterotopic ossification risk awareness in severe injury
Missed fracture risk reduction with post-reduction imaging and CT when indicated
Patient Discharge Instructions
copy discharge instructions
Home care and expectations
Splint and sling use continuously unless instructed otherwise
Keep splint clean and dry
Hand elevation above heart level for swelling
Pain control plan
Paracetamol as directed
NSAID if approved and no contraindications
Opioid only as prescribed, avoid driving or alcohol
Activity limits
No lifting or pushing with injured arm
Finger and hand range of motion several times daily
Return to ED immediately
Increasing pain not controlled by medication
Numbness or tingling in hand or fingers
Weakness opening or closing the hand
Fingers cold, pale, or blue
Rapidly increasing swelling
Splint feels too tight
Fever or increasing redness around any wound
Follow-up plan
Orthopedic appointment within recommended timeframe
Repeat imaging if instructed
Early motion program only when cleared by orthopedics
References
Guidelines and core sources
Reference set
ACEP clinical policy on procedural sedation and analgesia in the ED
Monitoring standards and staffing expectations
Adverse event mitigation principles
Orthopedic trauma references on elbow fracture dislocation management
Simple elbow dislocation early motion evidence summaries
Terrible triad operative indications and outcomes summaries
Decision aid sources
Elbow extension test derivation and validation studies
Use for X-ray decision support
Limitation in high-energy mechanisms
Fracture classification references
Mason radial head classification references
Regan Morrey coronoid classification references
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.