Reduction of Posterior Elbow Dislocation Periprocedural Care

Updated: Jul 15, 2016
  • Author: Nina Chicharoen, MD, MPH; Chief Editor: Erik D Schraga, MD  more...
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Periprocedural Care

Preprocedural Planning

Orthopedic consultation should be considered. Simple posterior elbow dislocations are treated with closed reduction. Complex posterior elbow dislocations (ie, those with associated fractures) require closed reduction; open reduction, internal fixation (ORIF); repair/reconstruction of ligaments; and/or dynamic external fixation. [5, 6, 7]

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Preprocedural Evaluation

Obtain a thorough history, and perform a complete physical examination. Evidence of neurovascular compromise is an indication for immediate closed reduction. In general, a clinical diagnosis of posterior elbow dislocation is sufficient, especially in adults. Achieving early reduction is often easier, given the presence of minimal muscle spasm and swelling.

Plain films of the elbow in the anteroposterior (AP) and lateral projections should be obtained to confirm the diagnosis and to determine the presence of fractures. Fractures of the distal humerus, radial head, and coronoid process occur commonly with this injury. It is particularly useful to obtain radiographic films in children before reduction: Ligaments and tendons in children are stronger than bone, making fractures more common. In children younger than 14 years, medial epicondyle separation is typically seen.

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Equipment

Materials required for aspiration include the following:

  • Syringe, 10 mL
  • Needle, 22 gauge
  • Povidone-iodine
  • Gauze

Materials required for regional anesthesia include the following:

  • Lidocaine 2% without epinephrine
  • Syringe, 10 mL
  • Needle, 22 gauge
  • Povidone-iodine
  • Gauze

Materials required for reduction include the following:

  • Stretcher or other stable surface
  • Assistant

Materials required for postreduction posterior long arm splinting include the following:

  • Undercast cotton padding
  • Plaster
  • Bandage, 4-in.
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Patient Preparation

Anesthesia

Use of intravenous analgesics should be considered. Analgesics may be administered before radiography.

Regional anesthesia is established via the following steps:

  • Locate the center of the triangle formed by the lateral olecranon, head of radius, and lateral epicondyle of humerus [8]
  • Sterilely prepare and drape the area
  • Insert the needle into the soft tissue within the triangle, directing it toward the opposite (medial) epicondyle
  • Aspirate to remove blood in the joint
  • Inject, in the same location and direction, 3-5 mL of lidocaine 2% without epinephrine
  • Gently move joint through its full range of motion to determine that pain relief has been achieved

General anesthesia is generally not necessary for closed reduction of uncomplicated posterior elbow dislocations. Procedural sedation is rarely needed in adults but may be preferred for use in children.

Positioning

The preferred approach to positioning is to place the patient prone on the stretcher with the affected arm flexed 90º over the edge (see the image below).

Reduction of posterior elbow dislocation. Prone po Reduction of posterior elbow dislocation. Prone positioning.

An alternative approach is to place the patient supine on the stretcher with the affected arm (humerus) in position against the stretcher. As another alternative, the patient may sit against a chair with the affected arm draped over the back of the chair.

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