What is the management of elbow dislocation in a 14-year-old post-reduction?

Post-Reduction Management of Elbow Dislocation in a 14-Year-Old

After successful closed reduction of an elbow dislocation in a 14-year-old, initiate early functional treatment with brief initial immobilization (typically 3 weeks maximum) followed by progressive range-of-motion exercises, as this approach enables faster return to function while achieving equivalent long-term outcomes to prolonged immobilization. 1, 2

Immediate Post-Reduction Assessment

• Confirm stability under fluoroscopy by testing joint widening at full extension, 30° of flexion, and with varus/valgus stress 3

  • <10° of widening indicates slight instability (conservative management appropriate)

  • 10° of widening indicates moderate instability (may still be managed conservatively but requires closer monitoring)

  • Frank redislocation with stress testing requires surgical fixation 3

• Document neurovascular status thoroughly, as nerve injuries can occur with pediatric elbow dislocations 3

• Obtain post-reduction radiographs to confirm concentric reduction and rule out associated fractures 1, 4

Immobilization Protocol

• Apply a posterior splint with the elbow at 90° flexion for initial immobilization 5

  • Posterior splinting provides superior pain relief compared to collar-and-cuff immobilization in the first 2 weeks 5

• Limit immobilization to 3 weeks maximum to prevent stiffness and muscular atrophy 1, 6, 2

  • Complete immobilization beyond this period increases risk of posttraumatic stiffness without improving stability 2

Early Mobilization Phase (After 3 Weeks)

• Begin active range-of-motion exercises at 3 weeks post-reduction 1, 2, 4

  • Early functional treatment enables faster return to activities (approximately 3 weeks earlier return to normal function) 2
  • Avoid passive stretching initially, as this may increase risk of ectopic ossification 1

• Progress to full range-of-motion exercises by 6 weeks, with most patients achieving full motion by this timeframe 4

Follow-Up Monitoring

• Obtain serial radiographs at 1 week, 3 weeks, and 6 weeks to monitor for late displacement and assess healing 5

• Evaluate for medial collateral ligament instability with valgus stress radiographs if persistent pain or instability symptoms develop 6

  • Persistent medial instability correlates with worse clinical outcomes, degenerative changes, and ectopic ossification 6
  • Consider MRI if clinical instability persists, as it can detect ligamentous injuries with 87.5-90.9% concordance with surgical findings 3

Critical Pitfalls to Avoid

• Do not immobilize beyond 3 weeks unless there is documented high-grade instability requiring surgical intervention 2

  • Prolonged immobilization does not improve long-term outcomes but significantly increases stiffness risk 2

• Do not assume stability without stress testing under fluoroscopy, as simple dislocations can have significant ligamentous injury 3, 6

• Watch for persistent valgus instability, which occurs in approximately 50% of cases and correlates with worse functional outcomes and degenerative changes 6

• Monitor for ectopic ossification, which occurs in up to 60% of cases and is associated with medial instability 6

Return to Activity

• Allow unrestricted activity at 6-8 weeks if full range of motion is achieved and stability is confirmed 1, 4

  • Earlier return to work/school activities (non-contact) can begin at 3-4 weeks with protective splinting 2

• Avoid contact sports for 8-12 weeks to allow complete soft tissue healing 1

When to Consider Surgical Intervention

• Persistent instability with >10° joint widening on stress fluoroscopy after reduction 3

• Irreducible dislocation or redislocation despite adequate closed reduction attempts 1

• Associated displaced fractures requiring fixation (though this would make it a complex rather than simple dislocation) 1