Fracture Dislocation of the Elbow

Aka: Fracture Dislocation of the Elbow

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II. Mechanism

  1. Fractures accompany most Elbow Dislocations
  2. High energy mechanism
    1. High speed MVA
    2. Fall from height
    3. Fall on Outstretched Hand
      1. Direct axial loading with valgus stress and supination

III. Types

  1. Elbow Posterolateral Fracture Dislocation (most common)
    1. Posterior Elbow Dislocation AND
    2. Radial Head Fracture AND
    3. Coronoid Process Fracture
      1. Terrible Triad (unstable) when accompanies Elbow Dislocation and Radial Head Fracture)
  2. Posteromedial Fracture Dislocation
    1. Coronoid Process Fracture (typically associated)
    2. Elbow Ulnar Collateral Ligament Injury (may be associated)
  3. Monteggia Fracture Dislocation
    1. Proximal ulnar Fracture
    2. Radial Head Dislocation
  4. Trans-Olecranon Fracture Dislocation
    1. Disrupted greater sigmoid notch or ulna and the olecranon

IV. Exam

  1. See Elbow Exam
  2. See Hand Neurovascular Exam
  3. Careful skin exam to exclude Open Fracture
  4. Neurovascular exam (esp. Ulnar Nerve)
  5. Compartment exam

V. Imaging

  1. Xray (AP, Lateral and Oblique)
    1. Define direction of dislocation
    2. Identify associated Fractures
  2. CT Elbow
    1. Recommended after reduction to define associated Fractures (XRay misses 40% of Fractures)

VI. Management

  1. Elbow closed reduction
    1. Performed under Procedural Sedation
      1. Alternatively, Regional Anesthesia with infraclavicular Brachial Plexus Block
      2. Itraarticular Anesthetic may also be adjunctive
    2. Technique
      1. See Elbow Dislocation
      2. Elbow slightly flexed
      3. Apply traction-countertraction
      4. Apply additional force to olecranon (medial or lateral) dependng on direction of dislocation
    3. Apply posterior Long Arm Splint with elbow flexed to 90 degrees
      1. Sling may be used in uncomplicated, simple reductions without Fracture or instability
    4. Recheck neurovascular exam after reduction
    5. Obtain post-reduction imaging (see above)
    6. Refer all Elbow Dislocations to orthopedics
    7. Return precautions include Compartment Syndrome
  2. Operative management
    1. Most patients will undergo surgical repair (e.g. radial head arthroplasty, coronoid repair, ligament repair)

VII. Complications

  1. Chronic elbow instability
  2. Post-Traumatic Arthritis
  3. Ulnar Nerve injury (stretch-induced Neuropraxia)
  4. Compartment Syndrome

VIII. References

  1. Kiel (2021) Crit Dec Emerg Med 35(9): 16-7
  2. Riveros (2026) Crit Dec Emerg Med 40(2): 21-2

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