Prehospital and Emergency Department Care
Prehospital personnel should splint the limb in the position found. Because of risk of neurovascular injury, field reduction is not recommended. Reduction is usually unsuccessful without adequate analgesia and sedation. Patients with neurovascular compromise should be transported rapidly to the closest facility.
Early reduction is essential because delay may increase the risk of neurovascular compromise or damage to articular cartilage. [12] The emergency physician should attempt reduction after obtaining appropriate radiologic studies if evidence of vascular compromise is noted or if orthopedic consultation is delayed significantly. [13, 14, 15]
Two methods are commonly used for posterior elbow reduction. Be certain that the patient has received adequate analgesic and sedative medications before beginning either procedure:
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With the elbow flexed to 90º and supinated, apply posterior pressure to the humerus while a second operator applies downward pressure on the proximal forearm. A coupling is felt and heard as the capitellum slides over the coronoid process and the joint realigns OR
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Use the Parvin method: Place the patient in the prone position with the humerus resting on the table and the forearm hanging perpendicular to the plane of the table. The humerus should be supported by the table, with padding just proximal to the elbow joint. Apply 5-10 lb of weight to the wrist, or gently pull down at the wrist. Perform reduction over a period of minutes as the muscles relax. Guide the olecranon into place if necessary.
Anterior dislocation reduction is performed with distal traction on the wrist and backward pressure on the forearm. Take care to avoid hyperextension at the elbow, which may cause traction and potential injury to neurovascular structures around the elbow.
Postreduction neurovascular check should always be performed, as the brachial artery and the median and ulnar nerves can become entrapped with manipulation.
Failed closed reduction is indicative of an entrapped medial epicondyle or an inverted cartilaginous flap. Reed et al have described a case of acute ulnar nerve entrapment after closed reduction. [16]
Patients with dislocation of the elbow should not be transferred until the elbow has been reduced. In hospitals without access to an orthopedic surgeon, reduction should be performed by the emergency physician prior to transfer.
Emergent orthopedic consultation should be sought for all patients with elbow dislocation. Vascular surgery consultation may be needed in patients with possible vascular injury.
Following reduction, splint the elbow in at least 90º of flexion using a posterior molded splint.
Arrange close follow-up care with the orthopedic surgeon.
In a self-reported study of patients sustaining simple elbow dislocation, despite a good long-term functional prognosis, a relatively high rate of residual pain and elbow stiffness was reported. Therefore, it is important for patients to receive timely outpatient follow-up with an orthopedic specialist. [17]
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Anteroposterior radiograph of the elbow demonstrates the normal anatomy.
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Lateral radiograph of the elbow demonstrates the normal anatomy.
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Lateral view of the elbow demonstrates a posterior dislocation of the elbow. The patient also had a nondisplaced radial head fracture.
