PT Classroom - Treatment of Elbow Dislocations  ׀ by Lauren Hogan, PT, DPT, ATC

Elbow dislocations make up between 11-28% of all elbow injuries. They are the second most common dislocation in adults and the most common in children under ten years of age (1). As a result, they are often seen by physical therapists for rehabilitation. The mechanism of injury for an elbow dislocation is usually a fall on an outstretched hand with the arm in abduction (1). Diagnosis is often relatively clear, as there is usually a deformity to the elbow with marked swelling. The elbow normally dislocates posteriorly or posteriolaterally, but could potentially move anteriorly or medially. X-rays can confirm the diagnosis and assess for fracture. A fat pad sign on the x-ray should increase suspicion of an intra-articular fracture and should be explored more thoroughly (2).

Given the traumatic mechanism of injury, 10-15% of patients have a secondary injury, often either to the wrist or shoulder (1). Physical therapists should be aware of the potential for missed injuries both above and below the elbow, and should assess patients appropriately. Health care providers should also be careful to rule out any neurovascular compromise, both before and after reduction of the dislocation. Ulnar or median nerve neuropraxia can occur with dislocations, and the radial nerve is at risk for injury with a concurrent radial head fracture (2). Brachial artery injury is rare, but a patient may have a decreased brachial pulse prior to reduction (2). Popping or locking of the elbow after reduction may indicate loose bodies within the joint and should raise suspicion.

In terms of classification, elbow dislocations are generally described as either simple or complex. A simple dislocation is an acute soft tissue injury, while a complex dislocation involves one or more fractures alongside significant soft tissue involvement.

Simple dislocations are usually treated with a closed reduction, generally in the emergency department, which has better outcomes than an open reduction (1). After reducing the dislocation, patients are put in a padded posterior elbow brace to protect the elbow (1). Position of the elbow and forearm should be considered with both bracing and rehabilitation. A patient with an RCL injury may be braced in pronation to increase stability, while a UCL injury is more stable in supination. Patients with multiple ligamentous injuries may be braced in neutral (2).

Range of motion often begins around one week post-injury. Active range of motion is preferable to passive, as passive range of motion may cause capsular tearing and increase swelling and inflammation (1). Full flexion generally returns in 6-12 weeks, while extension may continue to improve for up to 3-5 months (1). Patients lacking extension at six weeks may be prescribed an extension brace to assist with regaining motion (2). Strengthening may be held for 4-6 weeks to allow ligaments to heal and provide stability to the joint, but protocols do vary.

Simple dislocations that cannot maintain stability after reduction may be treated via open reduction. The surgery often involves reconstruction or repair of the radial collateral and/or ulnar collateral ligament. Patients are often braced for up to six weeks, with gradual ROM beginning 7-10 days post-surgery (2). Rehabilitation varies based on procedure performed and each individual surgeon’s protocol.

Complex dislocations involve some sort of fracture, often to the radial head or coronoid process. Other fractures may involve a medial or lateral epicondyle avulsion, capitulum, or the olecranon process. The so-called “terrible triad” involves a posterior dislocation with both a radial head and coronoid process fracture and often has less optimal outcomes (2).

Complex dislocations are generally treated with surgery, usually within 24 hours if the fracture is comminuted or unstable (2). If a patient’s elbow continues to lack stability after surgery, an external fixator may be applied. Along with repairing the fracture, the surgeon should attempt to restore normal positioning of the radial head and repair the collateral ligaments within the elbow. Healing in an adult can take between 12-18 weeks (2). Managing pain and controlling edema are important following surgery and patients may benefit from manual lymph drainage or kinesiotape post-surgery (2). Active and active-assistive range of motion exercises are started early to prevent stiffness. Gravity may be used with a passive hang to restore full extension ROM (2).

The physical therapist should be aware of the type of repair that was performed, as this will help to determine rehabilitation. Some potential fractures and surgical management are below (2).