What is the management for an irreducible elbow dislocation?

Management of Irreducible Elbow Dislocation

Irreducible elbow dislocations require urgent surgical intervention as closed reduction attempts will be unsuccessful and may cause further neurovascular injury. 1

Causes of Irreducible Elbow Dislocation

Elbow dislocations that cannot be reduced through standard closed techniques typically involve:

• Buttonholing of the radial head through the lateral collateral ligament complex 2
• Coronoid process wedged into a Hill-Sachs-like lesion in the capitellum 3
• Soft tissue interposition (including:
  • Brachialis muscle
  • Joint capsule
  • Annular ligament
  • Neurovascular structures)
• Osteochondral fragments blocking reduction

Initial Assessment and Management

1. Imaging:

   • Obtain orthogonal radiographs (AP and lateral views) to confirm dislocation and identify associated fractures 1
   • Proceed immediately to CT scan if initial closed reduction fails to better visualize:
     • Bony impediments to reduction
     • Fracture fragments
     • Joint congruity

2. Neurovascular Assessment:

   • Perform thorough neurovascular examination before and after any reduction attempt
   • Document status of:
     • Brachial artery pulse
     • Radial and ulnar pulses
     • Median, ulnar, and radial nerve function
     • Posterior interosseous nerve function
   • Consider Doppler ultrasound if vascular injury is suspected 4

3. Failed Closed Reduction Protocol:

   • Make only 1-2 gentle attempts at closed reduction under appropriate sedation/analgesia
   • If unsuccessful, do not persist with forceful manipulation as this may:
     • Cause iatrogenic fractures
     • Worsen neurovascular injury
     • Create additional soft tissue damage 3

Surgical Management

1. Timing:

   • Irreducible dislocations require urgent surgical intervention (within 6-12 hours) 1
   • Delay increases risk of compartment syndrome, neurovascular compromise, and poor functional outcomes

2. Surgical Approach:

   • Lateral approach for posterolateral dislocations (most common)
   • Anterior approach for anterior dislocations with suspected vascular injury 4
   • Combined approaches may be necessary based on specific pathology

3. Intraoperative Steps:

   • Identify and address the mechanical block to reduction:
     • Remove interposed soft tissues
     • Extract loose bodies or osteochondral fragments
     • Repair torn ligaments after reduction
   • Assess stability after reduction
   • Repair associated neurovascular injuries if present 4

4. Post-reduction Management:

   • Immobilize in a splint or removable cast at 90° flexion for 1-2 weeks 1
   • Begin early range of motion exercises as soon as stability allows
   • Avoid valgus stress for 4-6 weeks to protect medial collateral ligament healing

Complications and Their Management

1. Neurovascular Injury:

   • Brachial artery injury requires immediate vascular surgery consultation and repair 4
   • Consider fasciotomy if compartment syndrome is suspected or if reduction was delayed
   • Nerve injuries (especially ulnar and median) should be documented and monitored

2. Recurrent Instability:

   • May require ligament reconstruction
   • Consider hinged external fixator for severe instability

3. Post-traumatic Stiffness:

   • Early supervised motion is crucial once stable
   • Goal is to restore functional range of motion (≥30° to 130°) 5

Follow-up Protocol

• Weekly clinical assessment for first 3 weeks
• Radiographs at 2-4 weeks to confirm maintained reduction
• Consider advanced imaging (MRI) if persistent pain or instability occurs
• Functional assessment at 3 months to determine need for additional interventions

Remember that irreducible elbow dislocations represent a true orthopedic emergency, and persistent attempts at closed reduction when a mechanical block exists can lead to catastrophic complications. Early recognition and appropriate surgical management are essential for optimal outcomes.