Posterior Elbow Dislocation: Symptoms, Reduction Techniques, Rehabilitation, and Risks

How Do You Reduce a Posterior Elbow Dislocation?

Reducing a posterior elbow dislocation is a complex medical procedure that must only be performed by trained healthcare professionals. It involves specific maneuvers to realign the bones of the humerus, radius, and ulna, often requiring sedation and careful assessment to prevent further injury and ensure proper recovery.

Understanding Elbow Dislocation

The elbow is a hinge joint formed by the articulation of three bones: the humerus (upper arm bone), and the radius and ulna (forearm bones). It is stabilized by strong collateral ligaments (medial and lateral) and the joint capsule. A posterior elbow dislocation, the most common type, occurs when the ulna and radius are displaced backward relative to the humerus.

• Anatomy of the Elbow Joint: The olecranon process of the ulna articulates with the trochlea of the humerus, while the radial head articulates with the capitellum. The olecranon fossa on the posterior aspect of the humerus accommodates the olecranon during full extension. Dislocation typically involves the olecranon being forced out of this fossa and posterior to the humerus.
• Mechanism of Injury: Most posterior elbow dislocations result from a fall onto an outstretched hand (FOOSH) with the elbow in slight flexion and forearm supination. The axial load and valgus (outward) or varus (inward) stress can force the olecranon posteriorly, often tearing the collateral ligaments and joint capsule.
• Signs and Symptoms:
  • Severe Pain: Immediate and intense pain in the elbow.
  • Obvious Deformity: The elbow may appear grossly deformed, often with a prominent olecranon posteriorly and a shortened forearm.
  • Inability to Move: Significant limitation or complete inability to flex or extend the elbow.
  • Swelling and Bruising: Rapid onset of swelling and potential ecchymosis.
  • Numbness or Tingling: Possible signs of nerve impingement (especially the ulnar nerve) or vascular compromise.
• Why Immediate Medical Attention is Crucial: Prompt medical evaluation is critical due to the high risk of associated injuries, including fractures (e.g., radial head, coronoid process), nerve damage (ulnar, median, radial), and vascular compromise (brachial artery). Delaying reduction can increase swelling, make the reduction more difficult, and raise the risk of long-term complications.

The Principles of Elbow Reduction

The primary goal of elbow reduction is to restore the anatomical alignment of the humerus, radius, and ulna while minimizing further damage to surrounding soft tissues, nerves, and blood vessels.

• The Goal: To gently disengage the olecranon from its displaced position and guide it back into the trochlear notch of the humerus.
• Key Considerations Before Reduction:
  • Pain Management: Adequate analgesia, often involving intravenous pain medication and sometimes procedural sedation, is essential to relax muscles and facilitate reduction.
  • Imaging (X-rays): Pre-reduction X-rays are mandatory to confirm the dislocation type, rule out associated fractures, and identify any incarcerated fragments that might impede reduction.
  • Neurovascular Assessment: A thorough neurovascular exam (checking pulses, capillary refill, sensation, and motor function) must be performed before and after reduction to detect any compromise.
• Contraindications to Closed Reduction: While most elbow dislocations are treated with closed reduction, certain situations necessitate open surgical reduction, such as:
  • Open dislocations (bone piercing the skin).
  • Irreducible dislocations (cannot be reduced by closed means).
  • Dislocations with significant associated fractures that require surgical repair.
  • Vascular compromise that does not resolve with reduction.

Common Reduction Techniques (Performed by Medical Professionals)

The reduction techniques generally involve applying longitudinal traction to the forearm while counter-traction is applied to the upper arm, followed by specific maneuvers to guide the olecranon back into place.

• General Approach: The patient is typically positioned supine or prone, often with sedation. The goal is to overcome muscle spasm and gently manipulate the joint.
• Technique 1: The Traction-Countertraction Method (Most Common)
  • Patient Positioning: The patient lies supine. An assistant applies counter-traction to the humerus (often by grasping the upper arm).
  • Application of Forces: The primary operator grasps the patient's wrist or forearm.
  • Specific Maneuvers:
    1. Longitudinal Traction: Steady, gentle traction is applied along the long axis of the forearm, often with the elbow in slight flexion (around 60-90 degrees). This helps disengage the olecranon from the humerus.
    2. Gentle Supination: The forearm is often gently supinated to help unlock the radial head from any anterior displacement.
    3. Direct Pressure (Optional): In some cases, gentle, direct pressure may be applied to the olecranon posteriorly to guide it anteriorly.
    4. Flexion: As traction is maintained, the elbow is slowly flexed. A palpable "clunk" or "thud" often signifies successful reduction.
• Technique 2: The Supination and Forearm Traction Method (Similar to Stimson's Maneuver)
  • Patient Positioning: The patient lies prone with the dislocated arm hanging off the side of the bed, elbow flexed. A weight (e.g., 5-10 lbs) may be suspended from the wrist to provide continuous traction.
  • Application of Forces: After a few minutes of passive traction, the operator gently grasps the forearm.
  • Specific Maneuvers:
    1. Supination: The forearm is gently supinated.
    2. Gentle Flexion and Adduction: The elbow is gently flexed further, and the forearm may be gently adducted (moved towards the body) if needed.
    3. Direct Pressure: Gentle, anteriorly directed pressure may be applied to the olecranon.
• Important Notes During Reduction:
  • "Clunk" Sensation: A distinct "clunk" or "thud" is often felt and sometimes heard, indicating the olecranon has re-engaged with the trochlea.
  • Post-Reduction Assessment: Immediately after reduction, the elbow's stability, range of motion, and neurovascular status must be re-assessed. Post-reduction X-rays are crucial to confirm successful reduction and rule out any new or previously missed fractures.

Post-Reduction Care and Rehabilitation

Once the elbow is successfully reduced, proper post-reduction care and a structured rehabilitation program are essential to restore function and prevent complications.

• Immediate Post-Reduction:
  • Immobilization: The elbow is typically immobilized in a splint (often a posterior splint) at 90 degrees of flexion for a short period (usually 7-10 days) to allow initial soft tissue healing and reduce pain/swelling. Prolonged immobilization is generally avoided to prevent stiffness.
  • Neurovascular Re-assessment: Repeated checks of neurovascular status are critical.
  • Follow-up Imaging: Post-reduction X-rays confirm proper alignment and rule out new fractures.
• Rehabilitation Goals: The primary goals are to restore full, pain-free range of motion, regain strength, and return to pre-injury activities. Early, controlled motion is key to preventing stiffness.
• Phases of Rehab:
  • Phase 1: Protection and Early Motion (Weeks 1-3):
    • Focus on pain and swelling control.
    • Initiate gentle, passive, and active-assisted range of motion exercises within a pain-free range, often supervised by a physical therapist.
    • Avoid aggressive stretching or heavy lifting.
  • Phase 2: Progressive Strengthening (Weeks 3-8):
    • Gradually introduce isometric and light isotonic strengthening exercises for the elbow and surrounding musculature (biceps, triceps, forearm flexors/extensors).
    • Continue to progress range of motion, working towards full extension and flexion.
  • Phase 3: Return to Activity (Weeks 8+):
    • Incorporate functional movements, sport-specific drills, and progressive resistance training.
    • Emphasis on stability, power, and endurance.
    • Gradual return to high-impact activities or sports, guided by pain and functional assessment.

Risks and Potential Complications

Despite successful reduction, several complications can arise following an elbow dislocation.

• Associated Fractures: Up to 50% of elbow dislocations have associated fractures, commonly involving the radial head, coronoid process, or medial epicondyle. These may require surgical intervention.
• Neurovascular Injury: The ulnar nerve is most commonly injured, but median and radial nerves, as well as the brachial artery, can also be affected, leading to sensory deficits, motor weakness, or even limb ischemia.
• Recurrent Dislocation: While less common after a primary dislocation, factors like severe soft tissue damage, inadequate rehabilitation, or underlying ligamentous laxity can increase the risk of re-dislocation.
• Stiffness/Loss of Motion: This is the most common complication, particularly loss of full extension. Prolonged immobilization and insufficient early motion contribute to this.
• Heterotopic Ossification: The abnormal formation of bone in soft tissues around the joint, which can severely limit motion. This risk is higher with more severe injuries or multiple reduction attempts.
• Chronic Pain and Instability: Persistent pain or a feeling of instability can occur if soft tissue healing is incomplete or if there's significant ligamentous laxity.

Conclusion and Professional Recommendation

A posterior elbow dislocation is a serious musculoskeletal injury requiring immediate medical attention. While the principles of reduction involve specific traction and manipulation techniques, these are complex medical procedures that carry significant risks if performed improperly.

Under no circumstances should an untrained individual attempt to reduce an elbow dislocation. Doing so can cause further damage to nerves, blood vessels, ligaments, and bones, potentially leading to permanent disability. If you suspect an elbow dislocation, seek emergency medical care immediately. A healthcare professional will correctly diagnose the injury, rule out associated complications, perform the reduction safely, and guide you through the necessary post-reduction care and rehabilitation to ensure the best possible outcome.