Reduction of Posterior Elbow Dislocation Technique

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

Approach Considerations

Reduction of the posterior elbow dislocation may be accomplished by means of either a prone or a supine approach. The prone approach allows for more muscular relaxation, and this position should be considered as the initial approach. Multiple approaches may be required before reduction is successfully accomplished.

Posterior dislocations with associated fractures, also known as complex posterior dislocations, often require open reduction and fixation (ORIF). These dislocations are often associated with significant ligamentous injury. In some cases, complex posterior elbow dislocations may be managed with closed reduction.

Posterior elbow dislocations that are neglected, as is not uncommon in developing countries, can often be effectively treated with open reduction. [9]

Delayed vascular compromise is an important complication after reduction. All patients should be observed for a period of approximately 2-3 hours after reduction. If no evidence of vascular compromise arises, patients can be sent home with appropriate follow-up and instructions to watch for further problems.

A posterior long arm splint should be applied to the ulnar surface of the successfully reduced arm. The splint should also be secured so that the elbow is maintained at 90º of flexion and the forearm is positioned neutral to pronation and supination. The metacarpophalangeal (MCP) joints should be free to flex. For an illustrated demonstration of the application of a posterior long arm splint, see Posterior Long Arm Splinting.

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Prone Approach

One person

Place the patient in the prone position. Correct any medial or lateral translation of the proximal ulna. Grab the wrist of the injured arm. Apply traction and slight supination to the forearm. Attempt to distract and unlock the coronoid process from the olecranon fossa.

Using the other hand, apply pressure to the posterior aspect of the olecranon while the arm is pronated (see the image below). Reduction is achieved after an obvious "clunk" is appreciated. Restoration of normal joint contour should be noted

Reduction of posterior elbow dislocation. Prone (o Reduction of posterior elbow dislocation. Prone (one-person) technique.

Two persons

Place the patient in the prone position. Have an assistant, with his or her back toward the patient, encircle the humerus with both hands and apply pressure with the thumbs to the posterior aspect of the olecranon (see the image below).

Reduction of posterior elbow dislocation. Prone (t Reduction of posterior elbow dislocation. Prone (two-person) technique. Positioning of fingers against posterior olecranon.

Apply longitudinal traction to the arm with the elbow in slight flexion (see the image below). If reduction is not achieved, flex the elbow or have assistant lift the humerus. Reduction is signaled by a definite clunk.

Reduction of posterior elbow dislocation. Prone (t Reduction of posterior elbow dislocation. Prone (two-person) technique.
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Supine Approach

Place the patient in the supine position on the stretcher. Have an assistant stabilize the humerus against the stretcher with both hands. Grasp the wrist, and apply slow, steady, inline traction, keeping the elbow slightly flexed and the wrist supinated (see the image below).

Reduction of posterior elbow dislocation. Supine a Reduction of posterior elbow dislocation. Supine approach.

If success has not been achieved after 10 minutes, gently flex the forearm or apply traction to the proximal volar surface of the forearm (see the image below). Reduction is confirmed by hearing or feeling the characteristic clunk.

Reduction of posterior elbow dislocation. Supine a Reduction of posterior elbow dislocation. Supine approach, with addition of flexion and pressure against proximal volar surface of forearm.
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Postprocedural Care

Assess the stability of the elbow by gently moving the joint through its full range of motion, watching especially for instability upon elbow extension.

To apply a posterior long arm splint, flex the elbow 90º. Place the forearm in neutral position with respect to pronation and supination. Measure a plaster slab from the midhumerus to the palmar crease (see the image below). Wet the slab, and apply it to the ulnar border. Secure the slab with a 4-in. bandage, maintaining the elbow at 90º, keeping the forearm neutral to pronation and supination, and leaving the MCP joints free to flex.

Posterior long arm splint. Posterior long arm splint.

Neurovascular assessment is indicated, including evaluation and documentation of median nerve function, ulnar nerve function, and distal pulses. after splint placement.

Anteroposterior (AP) and lateral films of the elbow should be obtained to determine alignment and to reveal any associated fractures.

Because of the risk of delayed vascular compromise, patients should be observed for 2-3 hours after reduction. Some clinicians may opt to admit patients for such observation. Patients then can be discharged with adequate analgesia and instructions to ice and elevate the injury and to watch for signs of vascular compromise. An orthopedic follow-up visit should be arranged for the following day.

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Complications

The most serious complication of joint reduction for posterior elbow dislocation is brachial artery injury. Check for signs of delayed vascular compromise after reduction. If compromise is present, loosen the splint and decrease the degree of flexion. If pulse is not restored, immediately consult a surgeon to determine the need for emergency arteriography, exploration, or both.

Median or ulnar nerve injury may also occur. [10, 11]  New or increased injury after reduction may indicate entrapment. Immediately consult an orthopedist. Surgical intervention may be required.

Chronically unreduced posterior elbow dislocations have been observed to be associated with posttraumatic contracture of the elbow, periarticular ossifications. and loosening of the radial head endoprosthesis. [12]

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