What is the management of elbow dislocation in a patient?

Management of Elbow Dislocation

Immediate Reduction and Stability Assessment

After closed reduction of an elbow dislocation, immediately assess joint stability under fluoroscopy using stress testing, and initiate early functional treatment with brief immobilization (less than 3 days) followed by active range of motion exercises. 1

Post-Reduction Fluoroscopic Evaluation

• Perform stress fluoroscopy testing at full extension, 30° of flexion, and with varus/valgus stress to stratify instability 2, 1
• Classify stability based on joint widening:
  • <10° widening = slight instability (conservative management) 2

  • 10° widening = moderate instability (conservative management with close monitoring) 2

  • Frank redislocation with stress = gross instability (surgical fixation required) 2, 1
• Patients with mild instability achieve significantly better Mayo Elbow Performance Scores (77.6% vs 52.6%, P=0.043) compared to moderate instability 2

Neurovascular Documentation

• Thoroughly document neurovascular status immediately post-reduction, as nerve injuries can occur particularly in pediatric cases 1
• Assess for median, ulnar, and radial nerve function 3

Immobilization Protocol

Apply a posterior splint at 90° elbow flexion for initial pain control, but limit immobilization to less than 3 days before initiating active range of motion. 1, 4

Evidence-Based Rationale

• Early functional treatment (mobilization <3 days) is the evidence-based therapeutic standard for simple elbow dislocation 4
• Brief immobilization reduces initial pain, but long-term outcomes are equivalent between early mobilization and cast immobilization 4
• Critical pitfall: Immobilization >3 weeks is associated with poor outcomes, doubled after-treatment time, and prolonged disability 4, 5
• Early mobilization enables patients to return to work significantly earlier (mean difference -2.91 weeks, 95% CI -3.18 to -2.64) 4

Functional Rehabilitation

• Initiate early active range of motion as soon as possible (within 3 days) to minimize joint contracture 4, 6
• Late or recurrent instability is uncommon with early mobilization 6
• Expect average extension loss of 3-8° with standard management of simple dislocations 6

Imaging Follow-Up

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

Advanced Imaging Indications

• Order MRI without IV contrast if clinical instability persists despite appropriate conservative management 2, 1
• MRI demonstrates 87.5-90.9% concordance with surgical findings for medial and lateral collateral ligamentous complex injuries 2, 1
• MRI is particularly useful for detecting complete anterior capsule tears and collateral ligament injuries that may not be apparent on initial radiographs 2

Surgical Intervention Criteria

Proceed with surgical exploration and ligament repair for persistent instability with >10° joint widening on stress fluoroscopy or frank redislocation. 2, 1

Surgical Considerations

• No significant difference in outcomes between immediate ligament repair and delayed surgery based on meta-analysis 4
• Complex dislocations with associated fractures frequently require surgical intervention for joint stability 3
• Larger periarticular fractures adversely affect functional results 3
• Surgical management may involve lateral ligament repair/reconstruction and assessment for medial ligament repair 6

Common Pitfalls to Avoid

• Do not immobilize for >3 weeks: This more than doubles rehabilitation time and worsens outcomes 4, 5
• Do not miss associated injuries: Rule out wrist ligamentous injury (distal radioulnar joint disruption) which can be occult 3
• Do not delay mobilization: Contracture is the most common adverse sequela, not instability 6
• The extent of soft-tissue injury correlates inversely with clinical outcome (difference of mean values -12.07,95% CI -23.88 to -0.26) 4

Expected Complications

• Posttraumatic stiffness (most common) 3, 6
• Posterolateral joint instability (rare with appropriate early mobilization) 3
• Ectopic ossification 3
• Occult distal radioulnar joint disruption 3