What is the technique for reducing an elbow fracture-dislocation?

Elbow Fracture-Dislocation Reduction Technique

For posterolateral elbow dislocations (the most common pattern), use a single-person reduction technique with longitudinal traction on the forearm while the elbow is flexed to 20-30 degrees, applying gentle anterior pressure on the olecranon to disengage it from the olecranon fossa, then increase flexion while maintaining traction. 1

Pre-Reduction Assessment

• Obtain AP and lateral radiographs immediately to confirm dislocation direction (posterolateral is most common, followed by posteromedial, anterior trans-olecranon, and Monteggia variants) and identify associated fractures 2, 3
• Document neurovascular status before any manipulation, as nerve injury can occur with the initial trauma or during reduction 4
• Look specifically for the "terrible triad" pattern (posterolateral dislocation with radial head fracture and coronoid anterolateral facet fracture), as this indicates severe instability requiring surgical intervention 2

Reduction Technique Details

Single-Person Method (Preferred)

• Position the patient supine or sitting with the affected arm accessible 1
• Apply steady longitudinal traction on the forearm with the elbow initially at 20-30 degrees of flexion 1
• Place your thumb on the olecranon and apply gentle anterior pressure to disengage it from the olecranon fossa while maintaining traction 1
• Gradually increase elbow flexion to 90-120 degrees while continuing traction until you feel/hear the reduction 1
• This technique requires no sedation in many cases, no additional personnel, and has demonstrated no iatrogenic nerve, vascular, or fracture complications in reported series 1

Traditional Method (Alternative)

• Requires procedural sedation, additional personnel for countertraction, and more equipment 1
• Two patients failed traditional reduction but were successfully reduced with the single-person technique in one series 1

Post-Reduction Protocol

• Perform stress fluoroscopy immediately after reduction to quantify instability: <10° of joint widening indicates slight instability, >10° indicates moderate instability, and frank redislocation indicates gross instability requiring surgical fixation 5, 6
• Obtain CT without contrast if radiographs show persistent abnormal radiocapitellar alignment or if you suspect coronoid fractures, which are commonly missed on plain films but indicate severe instability 7
• Test joint stability under fluoroscopy at full extension, 30° of flexion, and with varus/valgus stress in pronation and supination 5
• Initiate active finger motion exercises immediately to prevent hand stiffness, which is functionally disabling 7

Critical Pitfalls

• Do not miss coronoid fractures, as they indicate severe instability and require CT imaging for identification—these are sequelae of prior dislocation and commonly undertreated 6, 7
• Do not assume stability after reduction—patients with moderate instability (>10° widening) demonstrate significantly worse Mayo Elbow Performance Scores compared to those with slight instability 5, 6
• Recognize that posteromedial dislocations involve anteromedial coronoid facet fractures with proximal lateral collateral ligament avulsion, requiring different surgical planning than posterolateral patterns 2
• Complex injuries with ipsilateral forearm shaft fractures require significant force and may be missed if you're not specifically looking for them 8

When Surgical Intervention is Mandatory

• Frank redislocation on stress testing requires immediate surgical fixation 5
• Terrible triad injuries (posterolateral dislocation + radial head fracture + coronoid fracture) require operative intervention with systematic repair: coronoid first, then radial head, then lateral soft tissues, and finally medial ligaments if instability persists 4
• Trans-olecranon fracture-dislocations with significant disruption of the greater sigmoid notch require operative fixation 2