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Reduction - Elbow dislocation

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This procedure may require procedural sedation, which is covered separately

Indications

Elbow dislocation

Contraindications (absolute in bold)

Life or limb-threatening conditions

Open dislocation

Associated fracture

Neurovascular compromise

Alternatives

Reduction by orthopaedic team in emergency department

Reduction in operating theatre

Informed consent

Medical emergency

Consent is not required if the patient lacks capacity or is unable to consent

Brief verbal discussion is recommended if the situation allows

or

Written consent

More complex non-emergency procedure with higher risk of complications

Potential complications

Failure (of reduction, recurrence or immobilisation)

Fracture

Conversion to an open injury

Compartment syndrome

Vascular damage (brachial artery spasm, thrombosis or rupture)

Nerve damage (ulnar most common)

Procedural hygiene

Standard precautions

Aseptic non-touch technique

PPE: non-sterile gloves

Area

Resuscitation bay

Staff

Procedural clinician and assistant

Additional clinicians required for procedural sedation

Equipment

Sling

Material for a long arm backslab (see separate procedure guide)

Positioning

Prone, semi-recumbent or supine in bed depending on approach

Medication

IV pain relief prior to procedure:

Fentanyl 50-100mcg or morphine 5-10mg IV titrated to relief of pain

Often followed by procedural sedation:

No single sedative agent recommended for every patient, typically

Nitrous oxide titrated 50-70% titrated to pain relief or

Bolus ketamine or propofol 1mg/kg (dose reduced to 0.3-0.5mg/kg if frail or elderly)

Further titrated 20mg boluses to minimum level required for patient comfort

Sequence (overall approach)

Provide analgesia

Examination for other injuries and fractures

Vascular assessment of hand (pulses, capillary refill)

Neurological assessment of hand: radial, median and ulnar nerves (power and sensation)

Bedside pre-reduction X-rays (see discussion)

If reduction cannot be achieved consult orthopaedics or a more experienced provider

We outline two approaches:

Modified Stimpson technique (single-provider technique without procedural sedation)

Position the patient prone with arm abducted and the flexed elbow hanging over the edge of the bed

With one hand apply traction to the distal forearm

With the other hand hold the humerus and place downward pressure on the olecranon

Maintain a slow, downward force along the long axis of the forearm

If unreduced, ask assistant to apply pressure on the olecranon with the thumbs

If unreduced, apply additional flexion to the elbow while maintaining traction

Listen and feel for a clunk as reduction is achieved

Traction-countertraction technique (two-provider technique with procedural sedation)

Position the patient supine on the bed (head slightly elevated if sedating patient)

Flex adducted arm to 90 degrees, supinate and support arm cross the body

Ask assistant to stabilise the humerus with both hands and apply countertraction

Apply slow steady traction to the distal forearm (for at least 10 minutes)

Ask assistant to apply pressure on the olecranon with the thumbs

Slight elbow flexion may help to facilitate the reduction

Listen and feel for a clunk as reduction is achieved

Post-procedure care

Check X-ray, circulation and limb function:

Reassess neurological vascular status (median, radial and ulnar sensation and power)

Reassess pulses and capillary refill (consider CT angiogram if any abnormality detected)

Assess range of joint motion through flexion and supination (consider entrapped medial epicondyle if limited)

Assesses for joint laxity compared to other elbow under varus and valgus stress (elbow in slight flexion)

Ongoing care:

Tetanus (ADT) and antibiotic cover (cefazolin 2g IV) for open wounds

Immobilise a long arm backslab with the elbow at 90 degrees for orthopaedic review within the next five days

Obtain post-reduction X-ray (patient should not leave the department until confirmed satisfactory)

Provide oral pain relief

Admit for three hours neurovascular observations (pain, sensation, motor function, perfusion)

Discuss follow-up and length of immobilisation with orthopaedic team

Document procedure, neurovascular assessments, X-ray findings and management plan

Tips

Always search for other fractures and serious injuries when treating a dislocated joint

Always perform a neurovascular exam before and after a relocation attempt

Reassurance, verbal distraction, effective pain relief and sedation all aid successful joint relocation

Slight traction distal to the dislocation is often enough to relocate the joint

Early orthopaedic team input recommended for fractures, neurovascular compromise, or non-posterior dislocations

Discussion

Elbow dislocations are usually posterior (90%) with associated medial (and occasionally lateral) collateral ligament injury. Anterior dislocations occur in rare cases, often involving serious trauma with associated fractures. We suggest non-posterior dislocations and those associated with fractures (complex injuries) are best managed after involvement of an orthopaedic surgeon.

Elbow dislocation may be confused with a supracondylar fracture. The two can be distinguished clinically by palpating for the equilateral triangle formed by the olecranon and epicondyles. This will be undisturbed in supracondylar fractures but distorted in elbow dislocations.

There a multiple methods of elbow reduction, generally involving supination, traction, pressure on the olecranon and flexion of the forearm. We have recommended a method suitable for a single provider without sedation and a traction-countertraction technique with sedation. We apply the traction-countertraction technique in the supine position with the arm across the chest. This may help the assistant more easily apply olecranon pressure. We have avoided leverage techniques which may place pressure in the antecubital fossa with risk of arterial or nerve injury in complex dislocations.

Vascular compromise or threatened skin penetration indicate the need for prompt relocation, however orthopaedic assessment and bedside pre-reduction X-rays are recommended to confirm dislocation and identify fracture dislocations prior to reduction attempts.

Consideration of fracture is particularly important in children where most dislocations are associated with fracture. Always look for medial epicondyle separation as the epiphyseal plate usually gives way before the medial collateral ligament.

Traditionally, the arm would be splinted for several weeks, however prolonged splinting may lead to joint fibrosis, stiffness and disability. Recent studies have evaluated early mobilisation with a sling and range of motion exercises for stable elbow dislocations. We recommend initially treating the joint as unstable with splitting until orthopaedic assessment.

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges’ clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.

Dunn RJ, Borland M, O’Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.

Chorley J. Elbow injuries in active children or skeletally immature adolescents: Approach. In: UpToDate. Waltham (MA): UpToDate. 2020 Jan 31. Available from: https://www.uptodate.com/contents/elbow-injuries-in-active-children-or-skeletally-immature-adolescents-approach

Gottlieb M, Schiebout J. Elbow dislocations in the emergency department: a review of reduction Techniques. J Emerg Med. 2018;54(6):849-854. doi:10.1016/j.jemermed.2018.02.011

Robinson PM, Griffiths E, Watts AC. Simple elbow dislocation. Shoulder Elbow. 2017;9(3):195-204. doi:10.1177/1758573217694163

Cohen MS, Hastings H 2nd. Acute elbow dislocation: evaluation and management. J Am Acad Orthop Surg. 1998;6(1):15-23. doi:10.5435/00124635-199801000-00002

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