Elbow Dislocation

History: typical mechanism is fall on outstretched hand with the elbow extended; immediate severe pain and inability to move the elbow; a palpable clunk is sometimes reported at the time of injury. In high-energy mechanisms, actively look for associated injury (ipsilateral wrist, shoulder, head).

Examination:

• •Gross deformity of the elbow, held in slight flexion
• •Prominent olecranon posteriorly in posterior dislocation
• •Soft-tissue swelling and ecchymosis, sometimes quickly extensive
• •Loss of active movement
• •Skin compromise: tented, blanching, or breached skin is a red flag for urgent reduction

Neurovascular examination (always document pre- AND post-reduction): radial, ulnar, and median nerve motor and sensory function; anterior interosseous nerve via OK sign; radial and ulnar pulses with capillary refill; compartment tension in the forearm.

Post-reduction stability assessment: range of movement at which the joint redislocates or subluxes (defines the safe arc); valgus and varus stress testing once analgesia allows; PLRI tests (lateral pivot shift, posterolateral drawer) typically deferred to clinic under anaesthesia if needed.

Differentials: supracondylar fracture (especially in children, similar deformity with typical fracture-tenderness pattern, distinguished radiographically); olecranon fracture without dislocation; radial head or neck fracture; isolated medial epicondyle avulsion (adolescents - fragment can be entrapped within the joint after spontaneous reduction); pulled elbow (radial head subluxation in toddlers from axial pull on a pronated forearm - not a true dislocation).

Plain radiographs (AP and true lateral) of the elbow are first-line before and after reduction. Confirm direction of dislocation and identify associated fractures (radial head, coronoid, olecranon, medial epicondyle). Post-reduction films are MANDATORY to confirm concentric reduction and exclude entrapped fragments. On the lateral view, check for concentric ulnohumeral alignment; a drop sign (widening of the ulnohumeral joint) suggests residual instability or incomplete reduction. The radiocapitellar line (drawn along the central axis of the proximal radial neck and head) must pass through the centre of the capitellum on ALL radiographic views - failure to bisect the capitellum is a critical clue to subtle radial head subluxation, Monteggia fracture-dislocations, or paediatric elbow injuries.

CT is indicated after reduction when any fracture is seen or suspected, and routinely in high-energy or complex injuries. Essential for characterising coronoid fractures (Regan-Morrey or O'Driscoll classifications), radial head fractures (Mason), and planning operative management.

MRI is not routine in acute management. Considered for persistent instability, suspected osteochondral injury, or planning ligament reconstruction for recurrent instability. PLRI is primarily a clinical and dynamic diagnosis; a normal MRI does not exclude it.

Additional: ipsilateral wrist and shoulder radiographs if clinical examination suggests associated injury; CT angiography if vascular injury is suspected clinically.

Open elbow dislocations are managed per BOAST-aligned open-injury principles: early IV antibiotics ideally within 1 hour, tetanus management, repeat neurovascular documentation, limited wound handling, saline-soaked dressing, photographic documentation, and urgent senior-led orthopaedic input.

Immediate approach: ABCDE and trauma assessment where mechanism warrants; analgesia (titrated IV opioid plus or minus procedural sedation); pre-reduction neurovascular examination and documentation; imaging (AP and lateral) before reduction unless reduction is urgent for skin or vascular compromise; reduction in the ED for simple dislocations, in theatre for complex or irreducible cases.

Reduction technique (simple posterior dislocation): adequate analgesia and sedation, patient supine; assistant counter-traction on the humerus; operator applies longitudinal traction on the forearm with the elbow in slight flexion, corrects medial/lateral translation, then flexes the elbow while pressing the olecranon anteriorly; a palpable clunk signals reduction; check range of movement and stability immediately; obtain post-reduction radiographs before splinting.

Simple dislocation, post-reduction: if concentric reduction and reasonable stability through a functional arc, above-elbow backslab in approximately 90 degrees flexion for 1-2 weeks MAXIMUM, then early protected active range of movement. Prolonged immobilisation beyond 2 weeks drives stiffness, which is the dominant long-term limitation. Routine fracture-clinic review within 1-2 weeks.

Complex dislocation is almost always operative. Specific patterns:

• •Terrible triad (posterior dislocation + radial head fracture + coronoid fracture): typically radial head fixation or replacement plus coronoid fixation plus lateral (LCL/LUCL) repair. The LCL is routinely repaired; the MCL is generally repaired only if the elbow remains grossly unstable after the radial head, coronoid, and lateral side have been addressed

• •Posteromedial fracture-dislocation (varus posteromedial rotatory instability): coronoid anteromedial facet fracture usually requires fixation
• •Monteggia-type: ulna fracture with radial head dislocation - ORIF of the ulna and ensure radiocapitellar joint reduction
• •Damage-control principles apply if patient or soft tissues preclude definitive fixation

Medial epicondyle avulsion in adolescents: common with posterolateral dislocation; fragments can become intra-articular after spontaneous or iatrogenic reduction. Intra-articular ENTRAPMENT is a clear operative indication. Displacement alone is more controversial - recent paediatric evidence (SCIENCE trial 2025-2026) suggests surgery does not clearly outperform non-surgical care for many displaced medial epicondyle fractures in children (entrapment and complex injuries excluded). All displaced cases need specialist assessment rather than automatic fixation.

Referral: urgent theatre/trauma referral for open dislocation, vascular compromise, irreducible dislocation, compartment syndrome, complex fracture-dislocation, or terrible triad. Routine fracture clinic within 1-2 weeks for all simple dislocations. Shoulder/elbow specialist for persistent stiffness, recurrent instability, or suspected chronic PLRI.

Typical pathway only. Progression depends on injury pattern, stability, and whether surgery was performed. Local protocols and surgeon or physiotherapist advice take precedence.

Simple dislocation (non-operative):

• •Backslab at approximately 90 degrees flexion for 1-2 weeks MAXIMUM
• •Begin early active and active-assisted range of movement at 1-2 weeks, within the safe arc identified at reduction
• •Avoid varus stress and terminal extension early if LCL injury dominates
• •Progressive strengthening typically from 4-6 weeks
• •Return to non-contact activity from 6-12 weeks; contact or overhead sport typically 3-6 months
• •Expect some residual loss of terminal extension

Complex dislocation (post-operative): protocol is surgeon-specific and depends on the fixation construct. Early controlled movement is usually encouraged to minimise stiffness, within repair limits. Return to heavy manual work or contact sport typically 4-6 months post-operatively, later for complex constructs.

Key rehabilitation principles:

• •Prolonged immobilisation is the enemy; stiffness is the dominant long-term limitation
• •Forceful passive stretching is CONTRAINDICATED. It exacerbates capsular trauma, worsens stiffness, and increases the risk of heterotopic ossification. Rehabilitation relies on active and active-assisted range of movement only
• •Static progressive or dynamic splints may be considered for persistent flexion contracture under specialist supervision
• •Heterotopic ossification prophylaxis (NSAIDs or radiotherapy) is occasionally used after high-risk injuries; decision is surgeon-led
• •Psychological and return-to-work support for manual workers; graded return and occupational modification

• •Horii circle (O'Driscoll, 1992) - The three-stage lateral-to-medial soft-tissue failure framework with 3A/3B/3C subdivisions. Underpins the principle that even a simple dislocation that reduces easily carries substantial capsuloligamentous disruption.
• •BOAST Management of Open Fractures - Governs open elbow dislocation: IV antibiotics within 1 hour, tetanus management, limited wound handling, photographic documentation, urgent senior orthopaedic input.
• •Terrible triad reconstruction principle - Radial head fixation or replacement plus coronoid fixation plus lateral (LCL/LUCL) repair is the standard sequence. MCL is repaired only if instability persists after the radial head, coronoid, and lateral side have been addressed.
• •SCIENCE trial (paediatric medial epicondyle, 2025-2026) - In children with displaced medial epicondyle fractures (excluding entrapment and complex injuries), surgery does not clearly outperform non-surgical care. Entrapped fragments remain a clear operative indication.
• •BESS shoulder and elbow guidance hub - UK framework for elbow trauma pathways including post-reduction follow-up at 1-2 weeks for all simple dislocations.

• •Elbow dislocation is the SECOND most common major joint dislocation in adults and the MOST common in children. Posterolateral dominates (more than 80% of cases). Simple (no fracture) vs complex (with fracture) drives the management split.
• •A simple dislocation reducing easily does NOT mean a minor injury - significant ligamentous disruption is always present. The coronoid is the bony keystone; even small coronoid fractures are clinically significant.
• •Terrible triad = posterior dislocation + radial head fracture + coronoid fracture. Highly unstable, almost always operative. In repair, the LCL is routinely fixed; the MCL is repaired only if gross instability remains.
• •Post-reduction radiographs are MANDATORY. Look for concentric reduction (parallel ulnohumeral surfaces on lateral), the drop sign of persistent widening, and confirm the radiocapitellar line passes through the centre of the capitellum in all views.
• •Simple dislocation: backslab 1-2 weeks MAXIMUM then early movement. Forceful passive stretching is CONTRAINDICATED in elbow rehabilitation - it worsens stiffness and increases heterotopic ossification risk. Use active and active-assisted movement only.
• •Adolescents: exclude entrapped medial epicondyle after reduction - the fragment can sit inside the joint. Entrapment is a clear operative indication; displacement alone is controversial and needs specialist assessment. Pulled elbow (radial head subluxation in toddlers) is NOT a true dislocation - different mechanism, different management.