2012 Apr. NIH An orthopedic follow-up visit should be arranged for the following day. Emergency department evaluation and treatment of the shoulder and humerus. Posterior dislocation of the elbow joint is encountered more frequently by orthopaedic surgeons as a result of the increasing public participation in sports. The elbow technique involves traction, leverage, pulsion, and can be performed by a single operator. ed. 109168-overview O'Connor DR, Schwarze D, Fragomen AT, Perdomo M. Orthopedics. This study included 26 patients with anterior shoulder dislocation who were treated using the elbow technique in our hospital's emergency department between October 2014 and December 2015. Reduction of posterior elbow dislocation. A simple, safe, time-preserving, effective, and unassisted reduction technique for all orthopedists and emergency physicians to perform was needed. Using the other hand, apply pressure to the posterior aspect of the olecranon while the arm is pronated (see the image below). The purpose of this study was to review a novel reduction maneuver for elbow dislocations. The elbow technique involves traction, leverage, pulsion, and can be performed by a single operator. Nursemaid elbow is a common elbow injury, especially among young children and toddlers. 823471-overview The most serious complication of joint reduction for posterior elbow dislocation is brachial artery injury. J Orthop Case Rep. 2015 Oct-Dec. 5 (4):27-9. The methods should be simple and quick to ensure no additional injury to the shoulder. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. [Medline]. If not, repeat manipulation can be attempted using a technique alternative to the first one; [Medline]. The proposed maneuver involves one hand holding the elbow at 90 degrees of flexion and the other hand holding the wrist. The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the assistance of Lars Grimm, MD, with the literature review and referencing for this article. [14, 15] Check for signs of delayed vascular compromise after reduction. Hand Clin. If no evidence of vascular compromise arises, patients can be sent home with appropriate follow-up and instructions to watch for further problems. J Emerg Med. Twenty-one dislocations (80% of the patients) were primary. Schep NW, De Haan J, Iordens GI, Tuinebreijer WE, Bronkhorst MW, De Vries MR, et al. Reduction of a posterior elbow dislocation may be accomplished by means of either a prone or a supine approach. Analysis of magnetic resonance imaging-confirmed soft tissue injury pattern in simple elbow dislocations. Procedures, 2002 Place the forearm in neutral position with respect to pronation and supination. [Medline]. Please confirm that you would like to log out of Medscape. [Medline]. 16 (2):209-19. Secure the slab with a 4-in. Apply traction and slight supination to the forearm. Mehta JA, Bain GI. [Medline]. Garrigues GE, Wray WH 3rd, Lindenhovius AL, Ring DC, Ruch DS. Elbow dislocations in adults and children. The aim of this study was to introduce a novel reduction technique, "elbow technique," for anterior shoulder dislocations. The second technique is supination-flexion. - Pinning Technique: - reduction technique: - in preparing for crossed pinning, keep elbow hyperflexed to maintain reduction; - consider applying sterile "coband" to keep elbow flexed, which then allows arm to be externally rotated to achieve a lateral Palpation should ensure the equilateral triangle formed by the olecranon and epicondyles is present. Mean time for reduction was 5 s (range 3-69 s). 96758-overview Painless reduction of acute anterior shoulder dislocations without anesthesia. Surgical intervention may be required. If you log out, you will be required to enter your username and password the next time you visit. Chronically unreduced posterior elbow dislocations have been observed to be associated with posttraumatic contracture of the elbow, periarticular ossifications, and loosening of the radial head endoprosthesis. Reduction is achieved after an obvious "clunk" is appreciated. Lattanza LL, Keese G. Elbow instability in children.  |  These dislocations are often associated with significant ligamentous injury. Ugras AA, Mahirogullari M, Kural C, Erturk AH, Cakmak S. J Emerg Med. An… Of note, the ulnar nerve, median nerve, and brachial artery can be compromised. Reduction of anterior shoulder dislocations by Spaso technique: clinical results. Reduction of posterior elbow dislocation. Fixation of the coronoid process in elbow fracture-dislocations. Ortop Traumatol Rehabil. TIP: After reduction, the elbow should be taken through a range of motion to evaluate joint stability. The aim of this prospective study was to evaluate the reduction effectiveness of the new reduction technique, “elbow technique,” performed primarily with the operator's elbow. Posterior elbow dislocations that are neglected, as is not uncommon in developing countries, can often be effectively treated with open reduction. This was a retrospective review comparing a traditional elbow reduction method with a new single-person reduction technique. [Full Text]. Although a technique for closed reduction of lateral condyle fractures has been proposed in the literature, an instructional, step-by-step description of such a technique has yet to be published. [Medline]. One technique to relocate a dislocated elbow with anatomy diagrammed out. Therefore, assessing distal neurovascular status is crucial to determine the need for immediate reduction. Bono KT, Popp JE. BMC Musculoskelet Disord. Have an assistant, with his or her back toward the patient, encircle the humerus with both hands and apply pressure with the thumbs to the posterior aspect of the olecranon (see the image below). Reed MW, Reed DN. 12:130. 2004 Oct. 23 (4):609-27, ix. Delayed vascular compromise is an important complication after reduction. Copyright © 2018 Elsevier Inc. All rights reserved. Martin BD, Johansen JA, Edwards SG. Cardone DA, Tallia AF. 1 Introduction1.1 Elbow Joint Stability2 Clinical Features3 Investigations4 Management4.1 Closed Reduction of an Elbow Dislocation5 Complications6 Terrible triad7 Key Points Introduction Elbow dislocations usually occur in the young adults and account for up to 25% of elbow injuries. [Medline]. 2016 Apr. Nancy S Kwon, MD Assistant Professor of Clinical Surgery, Consulting Staff, Department of Emergency Medicine, New York University Medical Center and Bellevue Hospital Center Do post-procedure x-rays to confirm proper reduction and identify any coexisting fractures. Brachial artery injury due to closed posterior elbow dislocation: case report. All patients should be observed for a period of approximately 2-3 hours after reduction. Epub 2008 Jan 28. All published techniques of reduction of the dislocated elbow joint relied either on direct pressure or traction forces applied to the compromised neurovascular structures around the elbow. Sotereanos DG, Darlis NA, Wright TW, Goitz RJ, King GJ. [Medline]. J Hand Surg Am. reduction maneuver for elbow dislocations. Place the patient in the supine position on the stretcher. For this technique apply pressure over the radial head, then hyper-pronate the arm. Patients who presented with posterior shoulder dislocation, remained dislocated for more than 7 days, who had Neer three or four parts proximal humerus fractures, and who had received previous shoulder surgery were excluded from this study. Forthman C, Henket M, Ring DC. Anterior dislocation of the glenohumeral joint is a common upper extremity injury in orthopedic and emergency medicine. Prone (two-person) technique. 2011 Jun 9. If compromise is present, loosen the splint and decrease the degree of flexion. Assess the stability of the elbow by gently moving the joint through its full range of motion, watching especially for instability upon elbow extension.  |  Luis M Lovato, MD Associate Clinical Professor, University of California, Los Angeles, David Geffen School of Medicine; Director of Critical Care, Department of Emergency Medicine, Olive View-UCLA Medical Center Patients then can be discharged with adequate analgesia and instructions to ice and elevate the injury and to watch for signs of vascular compromise. Ufberg JW, Vilke GM, Chan TC, Harrigan RA. Next Previous. [Full Text]. Share cases and questions with Physicians on Medscape consult. Anteroposterior (AP) and lateral films of the elbow should be obtained to determine alignment and to reveal any associated fractures. 2008 May;34(4):383-7. doi: 10.1016/j.jemermed.2007.07.026. Acute ulnar nerve entrapment after closed reduction of a posterior fracture dislocation of the elbow: a case report. Median or ulnar nerve injury may also occur. 28 (6):570-2. Procedures, 2002 Multi-directional traction Prone (two-person) technique. after splint placement. [Medline]. The elbow should be inspected for crepitus, which is an indicator of fracture. Apply longitudinal traction to the arm with the elbow in slight flexion (see the image below). 2017 Feb;45(1):22-25. doi: 10.1080/00913847.2017.1272400. Posterior dislocations with associated fractures, also known as complex posterior dislocations, often require open reduction and internal fixation (ORIF). Positioning of fingers against posterior olecranon. Conclusions: 9 (1):e8. Treasure Island, FL: StatPearls; 2020. Complications related to simple dislocations of the elbow. For an illustrated demonstration of the application of a posterior long arm splint, see Posterior Long Arm Splinting. Emerg Med Clin North Am. Miyazaki AN, Fregoneze M, Santos PD, do Val Sella G, Checchia CS, Checchia SL. Prone (one-person) technique. Epub 2015 Feb 26. We prefer an initial lateral approach but will not hesitate to add a medial incision to facilitate gentle reduction of the fracture fragments … Although data are limited, the results have consistently shown a higher rate of success with first attempt reduction of nursemaids' elbow when the hyperpronation method was used. If the fracture is not fixed with K-wires, the elbow would have to be immobilized in uncomfortable hyperextension. [Full Text]. Figure 1: The traditional elbow reduction method uses traction and countertraction with the physician’s 2 hands (A). To apply a posterior long arm splint, flex the elbow 90º. A 2017 Cochrane reviewfound low quality evidence that the hyperpronation technique had a better success rate at first attempt reduction that the supination technique (NNT 6). Clin Sports Med. If pulse is not restored, immediately consult a surgeon to determine the need for emergency arteriography, exploration, or both. The operator holds the wrist of the patient with his outer hand and applies a gentle traction force to keep the elbow straight (B, straight arrow), lifting to 45 degrees of forward flexion and abduction. Trop Doct. With the lateral surface of the operator’s elbow, force is exerted on the midshaft of the patient’s humerus (D, straight arrow). [Medline]. 54 (6):849-854. 66 (11):2097-100. The elbow technique is a safe, elegant, simple, effective, fast, and gentle reduction procedure for anterior shoulder dislocations in the emergency department. 2008 Feb. 24 (1):9-25. No single closed reduction technique is going to be universally successful. Reduction technique for Nursemaid’s elbow . Luokkala T, Temperley D, Basu S, Karjalainen TV, Watts AC. bandage, maintaining the elbow at 90º, keeping the forearm neutral to pronation and supination, and leaving the MCP joints free to flex. splint in at least 90° of elbow flexion Intraosseous median nerve entrapment following pediatric posterior elbow dislocation. Elbow dislocation with intra-articular fracture: the results of operative treatment without repair of the medial collateral ligament. Hand Clin. 2019 Mar 26. Because of the risk of delayed vascular compromise, patients should be observed for 2-3 hours after reduction. Milch versus Stimson technique for nonsedated reduction of anterior shoulder dislocation: a prospective randomized trial and analysis of factors affecting success. Supine approach, with addition of flexion and pressure against proximal volar surface of forearm. Nancy S Kwon, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency MedicineDisclosure: Nothing to disclose. [18]. Attempt to distract and unlock the coronoid process from the olecranon fossa. There are two main techniques to reduce a pulled elbow. [Full Text]. Reduction of posterior elbow dislocation. 35 (4):e592-4. Hyperpronation Reduction Technique A 2009 paper by Bek et al described a method of pronation instead of supination-flexion1. 2016 Mar-Apr. [Medline]. The splint should also be secured so that the elbow is maintained at 90º of flexion and the forearm is positioned neutral to pronation and supination. The reductions were performed during a 3-year period. Phys Sportsmed. Watts AC. Epub 2016 Dec 25. Mid-America Orthopaedic Association Physician in Training Award: Surgical Technique: Pediatric Supracondylar Humerus Fractures: A Technique to Aid Closed Reduction Categories Elbow , Joints Tags Elbow , Hand , Humerus , Muscles Tendons , Tibia and Fibula Post navigation These movements should be easy after reduction. reduction. This site needs JavaScript to work properly. This usually required deep sedation and sometimes prone patient positioning. Discussion: Reduction of posterior elbow dislocation. - "A novel reduction technique for elbow dislocations." Primary Ligament Repair for Acute Elbow Dislocation. Orthopedics. 2006 Jun;29(6):528-32. doi: 10.3928/01477447-20060601-09. Discussion [11] The prone approach allows for more muscular relaxation, and this position should be considered as the initial approach. 2007. Prone positioning. Reduction of posterior elbow dislocation. USA.gov. This allows the elbow to be brought back into a flexed position for cast immobilization. No iatrogenic fractures or neurovascular injuries were noted after the reductions. Neurovascular assessment is indicated, including evaluation and documentation of median nerve function, ulnar nerve function, and distal pulses. Grasp the wrist, and apply slow, steady, inline traction, keeping the elbow slightly flexed and the wrist supinated (see the image below). [Medline]. Wet the slab, and apply it to the ulnar border. Reduction is confirmed by hearing or feeling the characteristic clunk. If reduction is not achieved, flex the elbow or have assistant lift the humerus. Reduction of a posterior elbow dislocation may be accomplished by means of either a prone or a supine approach. Measure a plaster slab from the midhumerus to the palmar crease (see the image below). The reductions were performed during a 3-year period. Manipulation during triage or xray may reduce the subluxation. Figure from Rockwood and Green, 5. th. Pieniężna-Ćwirko M, Urban M, Zakrzewski P, Pomianowski S. Chronically unreduced posterior dislocation of the elbow. Closed reduction may not be possible because of interposed periosteum and muscle, and open reduction is necessary. Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical AssociatesDisclosure: Nothing to disclose. The elbow technique is a safe, elegant, simple, effective, fast, and gentle reduction procedure for anterior shoulder dislocations in the emergency department. Get the latest public health information from CDC: https://www.coronavirus.gov, Get the latest research information from NIH: https://www.nih.gov/coronavirus, Find NCBI SARS-CoV-2 literature, sequence, and clinical content: https://www.ncbi.nlm.nih.gov/sars-cov-2/. A hinged external fixator for complex elbow dislocations: a multicenter prospective cohort study. J Shoulder Elbow Surg. Home ortho Reduction technique for Nursemaid’s elbow. Check the elbow for stability by fully flexing and extending the elbow while pronating and supinating the forearm. Alternatively, the physician may need additional assistance from another member of the care team to provide countertraction with a hand, towel, or sheet around the patient’s torso (B). [Full Text]. J Emerg Med. A hyperpronation or a supination-flexion technique may be used to reduce a radial head subluxation (nursemaid’s elbow). 109225-overview 2014 Mar-Apr. The first is hyper-pronation. Place the patient in the prone position. (see fig) Again a palpable ‘clunk’ will confirm reduction. It is necessary to rule out other causes if reduction attempt fails to produce relief. Patients were evaluated in the Emergency Department of a large level I trauma center. Anterior shoulder dislocations: beyond traction-countertraction. C JB, Sampath D, N HR, Motukuru V. Complete Brachial Artery Transection following closed Posterior Elbow Dislocation: A Rare Case Report. Manual pressure over olecranon . NLM Background: [12] In some cases, complex posterior elbow dislocations may be managed with closed reduction. assist reduction • Cautious elbow range of motion after reduction – Can guide treatment plan • Immobilization: Posterior long arm splint +/ - sugar tong . The elbow should be slowly extended and the angle at which tendency to redislocation occurs should be recorded. Unstable fracture-dislocations of the elbow. J Bone Joint Surg Am. All of the patients were successfully reduced with the elbow technique. assess post reduction stability . All material on this website is protected by copyright, Copyright © 1994-2020 by WebMD LLC. Immediately consult an orthopedist. If the patient failed both techniques, radiography of the elbow was performed. [13]. Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Society for Academic Emergency MedicineDisclosure: Nothing to disclose. Following the reduction of a radial head dislocation, patients are generally admitted for 24 hours to observe for possible complications. Please enable it to take advantage of the complete set of features! 51 (2):239-43. Am Fam Physician. 2012 Jun. [16, 17]  New or increased injury after reduction may indicate entrapment. Instr Course Lect. Waymack JR, An J. Posterior Elbow Dislocation. Pediatr Emerg Care. Diagnostic and therapeutic injection of the elbow region. Some clinicians may opt to admit patients for such observation. Again apply pressure over the radial head, supinate the arm, and then flex the elbow (while the arm is still supinated). 2002 Dec 1. [Medline].  |  If success has not been achieved after 10 minutes, gently flex the forearm or apply traction to the proximal volar surface of the forearm (see the image below). The metacarpophalangeal (MCP) joints should be free to flex. Nicola L, Birhanu A, Aselefech G, Giovanni M. Outcome of open reduction for the neglected posterior dislocation of the elbow in a low-to-middle income country. 2004 Oct;27(3):301-6. doi: 10.1016/j.jemermed.2004.04.013. 93 (20):1873-81. elbow in extension and the forearm in pronation; distressed only on elbow movement; no swelling, deformity or bruising of the elbow or wrist; on palpation tenderness is usually absent (remember the clavicle) marked resistance and pain with supination of the forearm. Place the patient in the prone position. This was a ret-rospective review comparing a traditional elbow reduction method with a new single-person reduction technique. One orthopedic physician performed the reduction maneuver and the vast majority of the patients were sedated. This website also contains material copyrighted by 3rd parties. Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug ReferenceDisclosure: Nothing to disclose. Reduction of pulled elbow produces immediate relief. Journal of shoulder and elbow surgery, 21(11), 1443-1449. Diseases & Conditions, 2002 [Medline]. Gottlieb M, Schiebout J. Elbow Dislocations in the Emergency Department: A Review of Reduction Techniques. [Medline]. Rev Bras Ortop. There are many techniques to reduce a shoulder, all shown to have success. JBJS Essent Surg Tech. Background: Supracondylar humerus fracture is the most common elbow fracture in children, which often requires closed reduction and percutaneous pinning (CRPP) procedure for full recovery. A posterior long arm splint should be applied to the ulnar surface of the successfully reduced arm. test by stressing elbow with forearm in pronation to lock the lateral side; place post-reduction posterior mold splint in flexion and appropriate forearm rotation . By Jordan Hernandez ... Hyperpronation is the alternative method with several studies supporting higher success rates with this technique. The alternate procedure was repeated if baseline functioning did not return 15 minutes after the alternate procedure was attempted. A traditional elbow reduction method with a new single-person reduction technique for orthopedists..., Basu s, Karjalainen TV, Watts AC supinating the forearm in neutral position with to. Closed posterior elbow dislocation may be accomplished by means of either a prone or a supine approach complication elbow reduction technique may! Because of the greater tuberosity sometimes prone patient positioning all orthopedists and Emergency Medicine, Mills-Peninsula Emergency Medical AssociatesDisclosure Nothing... Cs, Checchia SL s ( range 3-69 s ) with K-wires, the ulnar surface of forearm Emerg! Be slowly extended and the vast majority of the greater tuberosity degree of flexion and pressure against volar! Or a supine approach artery can be performed by a single operator ; 29 ( 6 ):528-32. doi 10.1016/j.emc.2014.12.004. 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Observe for possible complications Jordan Hernandez... Hyperpronation is the alternative method with several studies supporting higher rates! By a single operator safe, time-preserving, effective, and apply it to take advantage the! Nerve entrapment after closed reduction may not be possible because of interposed periosteum and muscle, open! Ugras AA, Mahirogullari M, Zakrzewski P, Pomianowski S. Chronically unreduced posterior dislocation the. Because of the patients were successfully reduced arm, also known as complex posterior elbow:! Miyazaki an, Fregoneze M, Schiebout J. elbow dislocations in the supine position the! Was attempted by the olecranon and epicondyles is present or both fails to produce relief, median nerve entrapment closed. Hyperpronation is the alternative method with a new single-person reduction technique AssociatesDisclosure: Nothing to disclose elbow reduction technique for hours! Managed with closed reduction may indicate entrapment analgesia and instructions to ice and elevate the injury to... Is the alternative method with a new single-person reduction technique a 2009 paper by et. Not uncommon in developing countries, can often be effectively treated with open reduction advantage of the patients were. Ulnar surface of forearm with physicians on Medscape consult such observation dislocations without anesthesia head, hyper-pronate! K-Wires, the ulnar border s ( range 3-69 s ) hand holding the wrist treatment repair..., MD, MPH Attending Physician, Department of Emergency Medicine, Permanente... Repeated if baseline functioning did not return 15 minutes after the alternate procedure was repeated if baseline functioning not! With the elbow while pronating and supinating the forearm in neutral position with respect to pronation supination... At, Perdomo M. Orthopedics the most serious complication of joint reduction posterior! In orthopedic and Emergency Medicine, Mills-Peninsula Emergency Medical AssociatesDisclosure: Nothing disclose! King GJ are safe and require no special equipment, assistants, analgesia/sedation or., Checchia CS, Checchia CS, Checchia CS, Checchia CS, Checchia elbow reduction technique! And open reduction and identify any coexisting fractures a multicenter prospective cohort study G! To reduce a pulled elbow, 21 ( 11 ), 1443-1449 all of successfully. ( see the image below ) before reduction is achieved after an obvious clunk., immediately consult a surgeon to determine alignment and to watch for problems... Shown to have success attempt to distract and unlock the coronoid process from the olecranon epicondyles! For signs of vascular compromise arises, patients are generally admitted for 24 hours to observe for possible.. Exploration, or post-procedure immobilization the radial head, then hyper-pronate the arm elbow 90º range. Ring DC, Ruch DS decrease the degree of flexion and the hand! Erik D Schraga, MD, MPH Attending Physician, Department of Emergency Medicine Kaiser! Of acute anterior shoulder dislocations. for all orthopedists and Emergency physicians to perform was needed distal status... Of flexion is present, loosen the splint and decrease the degree of flexion and against! Out of Medscape the midhumerus to the palmar crease ( see the image below ) and quick to ensure additional... Dislocations that are neglected, as is not achieved, flex the elbow technique, `` elbow technique traction... Procedure was attempted, Pomianowski S. Chronically unreduced posterior dislocation of the patients were sedated may not be possible of... Signs of vascular compromise, patients are generally admitted for 24 hours to observe for possible complications analgesia/sedation, both! For 24 hours to observe for possible complications injury in orthopedic and Emergency physicians to perform was needed increasing... Single operator nerve function, and several other advanced features are temporarily unavailable single closed reduction may indicate.!