Initial Management of Left Elbow Dislocation
Perform immediate closed reduction after neurovascular assessment, followed by post-reduction radiographs and stress fluoroscopy to determine stability, then initiate early mobilization for stable reductions or surgical fixation for gross instability. 1, 2, 3
Immediate Assessment and Reduction
Pre-Reduction Neurovascular Examination
- Document radial pulse, capillary refill, and sensation in median, radial, and ulnar nerve distributions before any manipulation 4, 5
- Anterior dislocations (rare) carry higher risk of brachial artery and nerve injury compared to posterior dislocations (most common type) 4, 5
- Urgent vascular surgery consultation is required if pulse is absent or diminished 4
Reduction Technique
- Perform closed reduction urgently in the emergency department using traction-countertraction, patient-assisted countertraction, leverage approach, or modified Stimson technique 5
- Obtain post-reduction radiographs (AP, lateral, and oblique views) to confirm concentric reduction and rule out associated fractures 1, 6
Post-Reduction Stability Assessment
Stress Fluoroscopy Protocol
Perform dynamic fluoroscopy testing at full extension, 30° flexion, with pronation/supination, and varus/valgus stress to quantify instability. 1, 2
The degree of joint widening determines treatment pathway:
- <10° widening = slight instability: Conservative management with early mobilization 1, 2
- >10° widening = moderate instability: Conservative management but expect worse outcomes (MEPS 52.6% vs 77.6% for slight instability) 1
- Frank redislocation during stress testing = gross instability: Immediate surgical fixation required 1, 2
Identifying Surgical Indications
Urgent operative treatment is indicated for: 7, 8, 3
- Persistent instability or inability to maintain reduction
- Open injuries
- Vascular injury requiring repair
- Associated fractures (complex dislocation)
- Severe bilateral ligament injuries with moderate-to-severe instability on examination
Conservative Management for Stable Reductions
Early Mobilization Protocol
Begin active range of motion within 24-48 hours for stable simple dislocations to optimize outcomes. 3
- Early mobilization produces superior ROM compared to 3-week immobilization (extension deficit 16° ± 13° vs 19.5° ± 3°, p<0.05) 3
- Avoid immobilization beyond 1 week unless gross instability present 8, 3
- Physical therapy focusing on ROM and strengthening exercises 9, 3
- NSAIDs for pain control 9
Expected Outcomes
- Conservative treatment with early mobilization achieves excellent MEPS scores (92-95) and ROM (115-118°) in stable dislocations 3
- Patients with slight instability achieve significantly better functional scores than those with moderate instability 1
Surgical Management for Unstable Reductions
Operative Indications and Technique
- Surgical repair of lateral collateral ligament complex, medial collateral ligament, and capsule for gross instability 1, 2, 8
- Surgical outcomes are comparable to conservative treatment for stable injuries (MEPS 95 ± 7 vs 92 ± 4, ROM 115 vs 118°) but necessary for preventing recurrent posterolateral and valgus instability 3
- Post-operative early mobilization is equally important as in conservative management 3
Critical Pitfalls to Avoid
- Missing neurovascular injury: Always document pre- and post-reduction neurovascular status, as anterior dislocations frequently injure the brachial artery and nerves 4, 5
- Prolonged immobilization: Immobilization beyond 1 week in stable dislocations leads to significantly worse ROM and functional outcomes 3
- Undertreating moderate-to-severe instability: Patients with >10° widening on stress testing have substantially worse outcomes with conservative management alone 1, 2
- Failing to obtain stress fluoroscopy: Static radiographs alone cannot quantify instability; stress testing is essential for treatment planning 1, 2