Reduction - Elbow dislocation
This procedure may require procedural sedation, which is covered separately
Indications
Elbow dislocation
Contraindications (absolute in bold)
Life or limb-threatening conditions
Open dislocation
Associated fracture
Neurovascular compromise
Alternatives
Reduction by orthopaedic team in emergency department
Reduction in operating theatre
Informed consent
Medical emergency
Consent is not required if the patient lacks capacity or is unable to consent
Brief verbal discussion is recommended if the situation allows
or
Written consent
More complex non-emergency procedure with higher risk of complications
Potential complications
Failure (of reduction, recurrence or immobilisation)
Fracture
Conversion to an open injury
Compartment syndrome
Vascular damage (brachial artery spasm, thrombosis or rupture)
Nerve damage (ulnar most common)
Procedural hygiene
Standard precautions
Aseptic non-touch technique
PPE: non-sterile gloves
Area
Resuscitation bay
Staff
Procedural clinician and assistant
Additional clinicians required for procedural sedation
Equipment
Sling
Material for a long arm backslab (see separate procedure guide)
Positioning
Prone, semi-recumbent or supine in bed depending on approach
Medication
IV pain relief prior to procedure:
Fentanyl 50-100mcg or morphine 5-10mg IV titrated to relief of pain
Often followed by procedural sedation:
No single sedative agent recommended for every patient, typically
Nitrous oxide titrated 50-70% titrated to pain relief or
Bolus ketamine or propofol 1mg/kg (dose reduced to 0.3-0.5mg/kg if frail or elderly)
Further titrated 20mg boluses to minimum level required for patient comfort
Sequence (overall approach)
Provide analgesia
Examination for other injuries and fractures
Vascular assessment of hand (pulses, capillary refill)
Neurological assessment of hand: radial, median and ulnar nerves (power and sensation)
Bedside pre-reduction X-rays (see discussion)
If reduction cannot be achieved consult orthopaedics or a more experienced provider
We outline two approaches:
Modified Stimpson technique (single-provider technique without procedural sedation)
Position the patient prone with arm abducted and the flexed elbow hanging over the edge of the bed
With one hand apply traction to the distal forearm
With the other hand hold the humerus and place downward pressure on the olecranon
Maintain a slow, downward force along the long axis of the forearm
If unreduced, ask assistant to apply pressure on the olecranon with the thumbs
If unreduced, apply additional flexion to the elbow while maintaining traction
Listen and feel for a clunk as reduction is achieved
Traction-countertraction technique (two-provider technique with procedural sedation)
Position the patient supine on the bed (head slightly elevated if sedating patient)
Flex adducted arm to 90 degrees, supinate and support arm cross the body
Ask assistant to stabilise the humerus with both hands and apply countertraction
Apply slow steady traction to the distal forearm (for at least 10 minutes)
Ask assistant to apply pressure on the olecranon with the thumbs
Slight elbow flexion may help to facilitate the reduction
Listen and feel for a clunk as reduction is achieved
Post-procedure care
Check X-ray, circulation and limb function:
Reassess neurological vascular status (median, radial and ulnar sensation and power)
Reassess pulses and capillary refill (consider CT angiogram if any abnormality detected)
Assess range of joint motion through flexion and supination (consider entrapped medial epicondyle if limited)
Assesses for joint laxity compared to other elbow under varus and valgus stress (elbow in slight flexion)
Ongoing care:
Tetanus (ADT) and antibiotic cover (cefazolin 2g IV) for open wounds
Immobilise a long arm backslab with the elbow at 90 degrees for orthopaedic review within the next five days
Obtain post-reduction X-ray (patient should not leave the department until confirmed satisfactory)
Provide oral pain relief
Admit for three hours neurovascular observations (pain, sensation, motor function, perfusion)
Discuss follow-up and length of immobilisation with orthopaedic team
Document procedure, neurovascular assessments, X-ray findings and management plan
Tips
Always search for other fractures and serious injuries when treating a dislocated joint
Always perform a neurovascular exam before and after a relocation attempt
Reassurance, verbal distraction, effective pain relief and sedation all aid successful joint relocation
Slight traction distal to the dislocation is often enough to relocate the joint
Early orthopaedic team input recommended for fractures, neurovascular compromise, or non-posterior dislocations
Discussion
Elbow dislocations are usually posterior (90%) with associated medial (and occasionally lateral) collateral ligament injury. Anterior dislocations occur in rare cases, often involving serious trauma with associated fractures. We suggest non-posterior dislocations and those associated with fractures (complex injuries) are best managed after involvement of an orthopaedic surgeon.
Elbow dislocation may be confused with a supracondylar fracture. The two can be distinguished clinically by palpating for the equilateral triangle formed by the olecranon and epicondyles. This will be undisturbed in supracondylar fractures but distorted in elbow dislocations.
There a multiple methods of elbow reduction, generally involving supination, traction, pressure on the olecranon and flexion of the forearm. We have recommended a method suitable for a single provider without sedation and a traction-countertraction technique with sedation. We apply the traction-countertraction technique in the supine position with the arm across the chest. This may help the assistant more easily apply olecranon pressure. We have avoided leverage techniques which may place pressure in the antecubital fossa with risk of arterial or nerve injury in complex dislocations.
Vascular compromise or threatened skin penetration indicate the need for prompt relocation, however orthopaedic assessment and bedside pre-reduction X-rays are recommended to confirm dislocation and identify fracture dislocations prior to reduction attempts.
Consideration of fracture is particularly important in children where most dislocations are associated with fracture. Always look for medial epicondyle separation as the epiphyseal plate usually gives way before the medial collateral ligament.
Traditionally, the arm would be splinted for several weeks, however prolonged splinting may lead to joint fibrosis, stiffness and disability. Recent studies have evaluated early mobilisation with a sling and range of motion exercises for stable elbow dislocations. We recommend initially treating the joint as unstable with splitting until orthopaedic assessment.
Peer review
This guideline has been reviewed and approved by the following expert groups:
Emergency Care Institute
Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.
References
Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges’ clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.
Dunn RJ, Borland M, O’Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.
Chorley J. Elbow injuries in active children or skeletally immature adolescents: Approach. In: UpToDate. Waltham (MA): UpToDate. 2020 Jan 31. Available from: https://www.uptodate.com/contents/elbow-injuries-in-active-children-or-skeletally-immature-adolescents-approach
Gottlieb M, Schiebout J. Elbow dislocations in the emergency department: a review of reduction Techniques. J Emerg Med. 2018;54(6):849-854. doi:10.1016/j.jemermed.2018.02.011
Robinson PM, Griffiths E, Watts AC. Simple elbow dislocation. Shoulder Elbow. 2017;9(3):195-204. doi:10.1177/1758573217694163
Cohen MS, Hastings H 2nd. Acute elbow dislocation: evaluation and management. J Am Acad Orthop Surg. 1998;6(1):15-23. doi:10.5435/00124635-199801000-00002