eMedicine Specialties > Sports Medicine > Upper Limb
Elbow Dislocation: Treatment & Medication
Updated: Aug 12, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Acute Phase
Rehabilitation Program
Physical Therapy
Early ROM exercises in stable, reduced elbow dislocations has been shown to be associated with an improved outcome. However, immobilization of the affected elbow for longer than 3 weeks in patients following an elbow dislocation has been associated with loss of ROM compared with patients who start early ROM exercises.10
Medical Issues/Complications
- Brachial artery disruption may be seen in any elbow dislocation and special attention should be made in open dislocations.
- Ulnar nerve injury may occur in up to 15% of elbow dislocations. Perform an initial neurovascular assessment and frequent reassessments.
- Median nerve injury is frequently seen in conjunction with brachial artery injuries because both of these structures are in close anatomic proximity. The median nerve function should always be assessed with a higher suspicion of injury if a brachial artery injury is known to exist. The median nerve may also be injured or entrapped during a reduction.
- Associated fractures for elbow dislocation include those of the radial head or neck (5-10%), medial/lateral epicondyle avulsions (10%), those of the coronoid process (10%), and fractures of the distal radius, ulna, and proximal humerus (10%).
- Compartment syndrome may develop in the forearm fascia or biceps tendon due to massive swelling, which may occur in an acute elbow dislocation. Compartment syndrome must be considered in the differential diagnosis in the presence of persistent patient pain, particularly when exacerbations of pain occur with passive finger and wrist extension of the dislocated arm.
- Ectopic calcification, primarily around the collateral ligaments, is common after an elbow dislocation, provides no limitations and requires no intervention.
- Myositis ossificans may also be seen if significant hemarthrosis developed with the elbow dislocation.
Surgical Intervention
Seek surgical intervention by an orthopedist if any signs of neurovascular compromise, associated fractures, or nonreducible dislocations are present.
Related Medscape topics:
Resource Center Fracture
Resource Center Joint Disorders
Resource Center Vascular Surgery
Specialty Site Neurology & Neurosurgery
Specialty Site Orthopaedics
Specialty Site Surgery
Consultations
Obtain orthopedic consultation if any signs of neurovascular compromise, associated fractures, or nonreducible dislocations are present.
Recovery Phase
Rehabilitation Program
Physical Therapy
Patients with limitations in ROM on follow-up evaluation may benefit from more aggressive physical therapy to regain loss of mobility.
Maintenance Phase
Rehabilitation Program
Physical Therapy
Depending on the severity of the elbow dislocation, it may take several months for the elbow to fully heal. Muscle-strengthening activities, in addition to the ROM program, are important to improve endurance of the elbow. Incorporate sport-specific training as the athlete progresses through rehabilitation to ensure a safe return to his/her sport.13
Related Medscape topic:
Resource Center Exercise and Sports Medicine
Surgical Intervention
Surgical intervention may be needed for a functional flexion contracture or for chronic residual instability.14,15,16
Medication
Use of medication for elbow dislocations is beneficial in the acute setting when reduction of the dislocation is to take place. Choosing both an anxiolytic and a pain medication is ideal for a conscious sedation to facilitate reduction. Once reduction has occurred, pain may still be an issue, and it would be reasonable to provide the patient with oral pain medication to use in the outpatient setting.
Anxiolytics
Anxiolytics allow for relaxation and mild sedation when reduction of a dislocated elbow is attempted. These agents also allow for a lower dose of analgesics to be used.
Midazolam (Versed)
DOC for anxiolytics. Shorter-acting benzodiazepine sedative-hypnotic that is useful in patients requiring acute and/or short-term sedation. Midazolam is also useful for its amnestic effects.
Adult
2.5-5 mg IV; not to exceed 2.5 mg IV over 2 min; not to exceed a total of 10 mg
Allow 2-3 min between doses to assess effect.
May start with 1 mg IV and slowly titrate to effect.
Pediatric
0.05-0.1 mg/kg IV; not to exceed the total dose of 10 mg
0.05-0.15 mg/kg IM 30-60 min before the procedure; not to exceed the total dose of 10 mg
0.25-0.5 mg/kg PO; not to exceed the total dose of 10 mg
Intranasal: 0.2 mg/kg; may repeat in 5-15 min
CNS depressants; alcohol may increase sedation and respiratory depression; narcotic agents may increase hypotension; may increase midazolam serum concentrations with cimetidine, ranitidine, erythromycin, diltiazem, verapamil, fluconazole, ketoconazole, itraconazole; protease inhibitors may decrease the midazolam metabolism
Documented hypersensitivity to midazolam, any components, and cherries (syrup only); acute narrow-angle glaucoma; existing CNS depression
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients with renal and hepatic impairment, CHF, and pulmonary disease; respiratory/cardiac monitoring is essential during sedation in children
Lorazepam (Ativan)
Sedative hypnotic with short onset of effects and a relatively long half-life. By increasing the action of gamma-aminobutyric acid (GABA), which is a major inhibitory neurotransmitter in the brain, this agent may depress all levels of CNS, including the limbic and reticular formation. When the patient needs to be sedated for longer than a 24-hour period, this medication is excellent.
Adult
1-4 mg/dose IV given slowly over 2-5 min; may repeat in 10-15 min; not to exceed 8 mg/12 h
Pediatric
0.05 mg/kg PO/IM (range 0.02-0.09 mg/kg)
0.05 mg/kg IV (range 0.02-0.09 mg/kg; may consider smaller doses 0.01-0.03 mg/kg) and repeat q20 min to achieve effect; give slow IV
Other CNS/respiratory depressants may increase effects
Documented hypersensitivity; narrow-angle glaucoma; severe hypotension
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Use with caution in patients with impaired renal or hepatic function or who have compromised pulmonary function.
Diazepam (Valium)
Depresses all levels of the CNS (eg, limbic and reticular formation), possibly by increasing the activity of GABA. Individualize the dosage and increase cautiously to avoid adverse effects.
Adult
10 mg PO
5 mg IV; may repeat with 2.5 mg if needed
Pediatric
0.2-0.3 mg/kg PO; not to exceed 10 mg; 45-60 min before the procedure
0.04-0.3 mg/kg/dose IV/IM; not to exceed 0.6 mg/kg in 8h period
CNS depressants, cimetidine, and erythromycin may decrease metabolism; valproic acid may displace diazepam from the binding sites, resulting in increased sedation; use with ritonavir is not recommended
Documented hypersensitivity to diazepam or any component (emulsified diazepam injection contains soybean oil, egg yolk, phospholipids); comatose patients; narrow-angle glaucoma
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients with other CNS depressants; hypoalbuminemia, and liver or hepatic dysfunction
Analgesics
Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who have sustained trauma or who have sustained injuries.
Related eMedicine topics:
Toxicity, Acetaminophen
Toxicity, Narcotics
Related Medscape topics:
Resource Center Adverse Drug Events Reporting
Resource Center Opioids: A Guide to State Opioid Prescribing Policies
Resource Center Pain Management: Advanced Approaches to Chronic Pain Management
Resource Center Pain Management: Pharmacologic Approaches
Morphine (Duramorph, Astramorph, MS Contin)
Indicated for moderate to severe acute and chronic pain.
Adult
2.5-20 mg/dose IV/IM/SC; usual dose of 10 mg; dosing q2-6h
Pediatric
<12 years: 0.05-0.1 mg/kg IV 5 min before the procedure
>12 years: 3-4 mg IV; may repeat in 5 min prn
Phenothiazines may antagonize the analgesic effects of opiate agonists; tricyclic antidepressants, MAO inhibitors, and other CNS depressants may potentiate the adverse effects of morphine.
Documented hypersensitivity to morphine sulfate; increased intracranial pressure; severe respiratory depression; severe liver or renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Avoid in the presence of hypotension, respiratory depression, nausea, emesis, constipation, and urinary retention; caution in patients with atrial flutter and other supraventricular tachycardias; has vagolytic action and may increase the ventricular response rate
Fentanyl (Duragesic, Sublimaze)
Potent narcotic analgesic with a much shorter half-life than morphine sulfate. DOC for conscious sedation analgesia. Ideal for analgesic action of short duration during anesthesia and immediate postoperative period.
Excellent choice for pain management and sedation with short duration (30-60 min) and easy to titrate. Easily and quickly reversed by naloxone. After initial dose, the subsequent doses should not be titrated more frequently than q3h or q6h thereafter.
When using the transdermal dosage form, most patients are controlled with 72 h dosing intervals. However, some patients require dosing intervals of 48 h.
Adult
25-50 mcg IV; repeat doses of 25 mcg up to 4-5 times q5 min if needed
Pediatric
1-2 mcg/kg/dose IV/IM with repeated doses at 30-min intervals prn
Phenothiazines may antagonize the analgesic effects of opiate agonists; tricyclic antidepressants may potentiate the adverse effects of fentanyl when both drugs are used concurrently.
Documented hypersensitivity; increased intracranial pressure; severe hepatic or renal insufficiency; severe respiratory depression
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in the presence of hypotension, respiratory depression, constipation, nausea, emesis, and urinary retention; idiosyncratic reaction, known as chest wall rigidity syndrome, may require neuromuscular blockade in order to increase ventilation.
Oxycodone and acetaminophen (Percocet, Roxicet)
Drug combination indicated for the relief of moderate to severe pain.
Adult
1-2 tab PO q4-6h prn
Pediatric
0.05-0.15 mg/kg/dose up to 5 mg/dose PO q4-6h based on oxycodone component
Phenothiazines may decrease the analgesic effects of this medication; the toxicity increases with the coadministration of either CNS depressants or tricyclic antidepressants.
Documented hypersensitivity to oxycodone, acetaminophen; severe liver or renal insufficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
The duration of action may increase in the elderly; be aware of the total daily dose of acetaminophen the patient is receiving; do not exceed 4,000 mg/24h of acetaminophen; higher doses may cause liver toxicity.
Acetaminophen and codeine (Tylenol with codeine, Tylenol #3)
Indicated for the treatment of mild to moderate pain.
Adult
1-2 tab PO q4h; not to exceed 12 tab/24 h
Pediatric
<3 years: 0.5-1 mg codeine/kg/dose PO q4-6h
3-6 years: 5 mL PO tid/qid prn
7-12 years: 10 mL PO tid/qid prn
>12 years: 15 mL PO q4h prn
CNS depressants, alcohol, phenothiazines, and tricyclic antidepressants can increase the adverse effects of codeine or increase the hepatotoxicity of acetaminophen
Documented hypersensitivity to acetaminophen, codeine, or any component
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients with hypersensitivity to morphine, hydromorphone, levorphanol, oxycodone, oxymorphone, and hydrocodone
Acetaminophen and hydrocodone (Vicodin, Hydrocet, Lorcet)
Drug combination indicated for moderate to severe pain.
Adult
1-2 tab or cap PO q4-6h prn
Pediatric
Not established
Coadministration with phenothiazines may decrease analgesic effects; the toxicity increases with CNS depressants or tricyclic antidepressants
Documented hypersensitivity to hydrocodone, acetaminophen; CNS depression; severe respiratory depression
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
The tablets contain metabisulfite, which may cause hypersensitivity; caution in patients who are dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in patients with severe renal or hepatic dysfunction
More on Elbow Dislocation |
| Overview: Elbow Dislocation |
| Differential Diagnoses & Workup: Elbow Dislocation |
 Treatment & Medication: Elbow Dislocation |
| Follow-up: Elbow Dislocation |
| Multimedia: Elbow Dislocation |
| References |
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References
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Further Reading
Keywords
elbow dislocation, dislocation of elbow, dislocated elbow, radial head dislocation, ulnar dislocation, radial head subluxation, FOOSH injury, falling on an outstretched hand, nursemaid's elbow, elbow injury, elbow trauma
