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OverviewAetiologyPathophysiologyClinical features and red flagsInvestigationsDifferential diagnosisManagementComplicationsMonitoring and follow-upSpecial situationsCommon pitfallsQuestionsSources
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Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.

Elbow dislocation and radial-head fracture

Musculoskeletal medicine and orthopaedics · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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A deformed elbow can threaten the limb

Dislocation may injure brachial artery and median, ulnar or radial nerves; associated coronoid or radial-head fracture can make the joint unstable after apparent reduction.

Action: Give prompt analgesia, inspect skin and document pulses and named nerve functions, obtain imaging unless vascular or skin compromise makes delay unsafe, perform controlled reduction with suitable sedation, and repeat examination and radiographic and stability assessment.

Overview

Recognise elbow dislocation and radial-head fracture, identify vascular and nerve threats, achieve safe reduction and post-reduction stability assessment, and restore motion without missing complex instability.

The elbow gains stability from ulnohumeral congruence, coronoid and radial head plus collateral ligaments and muscle. A simple dislocation has no major fracture; a complex dislocation does. Record the mechanism and examine shoulder, forearm and wrist. Median and brachial structures lie anteriorly, ulnar nerve medially and radial structures laterally, so testing only one hand territory is insufficient.

Reduction is followed by proof: radiographic congruence, stable safe motion arc and repeat nerve and vascular examination. CT defines coronoid or radial-head fragments when complex injury is suspected. Stable simple dislocation benefits from early movement, while unstable patterns may need radial-head fixation or replacement, coronoid repair and ligament reconstruction. Radial-head fractures without block or instability often follow non-operative movement; excision is not a casual acute solution because the radial head is a stabiliser.

Practice

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Musculoskeletal medicine and orthopaedicsOriginal SBA

Complex elbow instability

An elbow dislocation is accompanied by radial-head and coronoid fractures on post-reduction imaging. What does this combination imply?

Choose one answer, then submit
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Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • AO Surgery Reference: Terrible triad – elbow dislocation with radial-head and coronoid fractures
  • AO Surgery Reference proximal forearm trauma
  • NICE NG38 fractures non-complex assessment and management
  • BOAST peripheral nerve injury

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateComplete draftClinical stateAwaiting reviewJurisdictionUnited Kingdom
Radial-head fracture description includes displacement, comminution, articular involvement and whether forearm rotation is mechanically blocked after local anaesthesia and analgesia. A minimally displaced fracture without block or instability commonly uses a sling briefly and early motion. A reconstructible displaced fragment may be fixed; severe comminution in an unstable adult elbow may require radial-head replacement. Excision alone removes a valgus and axial stabiliser and is unsafe when the interosseous membrane, medial collateral ligament or coronoid is deficient. The wrist and distal radioulnar joint must therefore be examined every time.

Reduction of a simple posterior dislocation uses adequate analgesia or sedation, steady traction and correction of displacement without forceful levering. After relocation, obtain AP and lateral films and assess stability through a controlled range. An elbow that subluxes outside a narrow flexion arc is not suitable for routine discharge. CT defines occult coronoid, radial-head or capitellar fracture. Open injury, entrapped fragments, failed reduction or neurovascular change requires theatre. Document the exact stable arc and forearm position because this guides the hinged brace and therapy programme.

Rehabilitation balances instability against rapid capsular stiffness. Begin active motion within the protected arc once the joint is demonstrably stable, often avoiding valgus or posterolateral stress initially. Monitor extension loss, heterotopic ossification and ulnar symptoms. Persistent lateral pain, clicking or blocked rotation requires reassessment of the radial head and capitellum. Recurrent apprehension or subluxation after a supposedly simple injury may indicate missed collateral disruption and warrants specialist imaging rather than a second prolonged period of immobilisation.

Children require interpretation of ossification centres and can sustain medial epicondyle entrapment with dislocation. Older adults may have osteoporotic coronoid or radial-head comminution and greater stiffness risk. Anticoagulation increases haemarthrosis but is not a reason to aspirate routinely; review the bleeding indication and avoid delaying reduction. In pregnancy, use indicated radiography with optimised technique and select analgesia and VTE assessment for gestation. Across groups, early functional goals should be written as degrees and permitted activities rather than 'mobilise as tolerated' alone.

A post-reduction neurological deficit needs localisation. Test thumb and index flexion for anterior interosseous function, thumb opposition and palmar sensation for median nerve, finger abduction for ulnar nerve and wrist, finger and thumb extension for radial branches. A multi-nerve pattern or vascular change after a high-energy injury raises concern for broader stretch or compression. Remove external constriction, recheck joint position and obtain urgent senior review. Persistent deficit follows a named peripheral-nerve pathway with protection, therapy and appropriately timed electrodiagnostic assessment.

Return-to-function advice should include lifting, driving and sport. A patient should not drive while unable to control the wheel safely or while impaired by a sling or sedating medicine. Strengthening begins only after stable motion is established. Contact athletes progress through pain-free range, strength and sport-specific control before return. Explain that temporary loss of terminal extension is common but a worsening block, recurrent deformity, hand symptoms or locking requires reassessment. This detail reduces both unnecessary fear and dangerous delay.

Key points

  • Posterior elbow dislocation produces obvious deformity and loss of normal olecranon relationships, but associated fractures define whether it is simple or complex.
  • Document radial and ulnar pulses, refill, median and anterior interosseous, ulnar and radial motor and sensory functions before and after reduction.
  • Obtain AP and lateral elbow radiographs before reduction unless perfusion or skin is threatened; image the full forearm when another injury is suspected.
  • Perform prompt controlled reduction under adequate analgesia or sedation, avoiding repeated attempts when fracture or entrapment is likely.
  • After reduction, repeat neurovascular findings, obtain radiographs and assess stability through a specialist-directed safe arc.
  • A stable simple dislocation uses brief support followed by early guided motion; prolonged casting causes marked stiffness.
  • Radial-head fracture treatment depends on displacement, mechanical block, comminution and associated instability, not fragment size alone.
  • Wrist pain or distal radioulnar tenderness with radial-head fracture requires assessment for interosseous-membrane disruption.
  • Open injury, terrible triad, irreducibility, vascular compromise or unstable post-reduction joint needs early operative management.

Aetiology

01

Fall on outstretched hand

Axial load with valgus and rotational force disrupts lateral then medial stabilisers, usually producing a posterior elbow dislocation.

02

Axial radial-head load

Force transmitted from wrist through radius impacts the capitellum, fracturing the radial head and sometimes disrupting interosseous membrane.

03

Direct high energy

Collision or fall from height can create open fracture-dislocation, extensive comminution and associated vascular or multi-nerve injury around the elbow.

Pathophysiology

  1. 1
    Sequential ligament failure

    Posterolateral rotatory force disrupts lateral collateral structures and capsule and may progress to complete dislocation and medial injury.

  2. 2
    Bony stabiliser loss

    Radial head and coronoid resist valgus and posterior translation; combined fracture leaves the reduced elbow mechanically vulnerable.

  3. 3
    Neurovascular stretch

    The displaced forearm can stretch median and ulnar nerves and brachial artery across the joint, producing change before or after reduction.

  4. 4
    Stiffness biology

    Haemarthrosis, capsular injury and immobilisation rapidly restrict elbow motion, making stable early movement a key treatment goal.

Clinical features and red flags

Posterior dislocationRed flag

Painful deformity with prominent olecranon and shortened forearm follows a fall on the outstretched hand.

Radial-head fracture

Lateral elbow tenderness, haemarthrosis and painful or blocked forearm rotation are characteristic.

Terrible triadRed flag

Dislocation with radial-head and coronoid fractures signals complex instability and operative-level review.

Brachial-artery threatRed flag

Coolness, pulse loss, refill delay or expanding antecubital swelling requires immediate action.

Longitudinal forearm injuryRed flag

Wrist pain and distal radioulnar instability with radial-head fracture suggests an Essex-Lopresti pattern.

Red flags requiring action

  • A cool hand, absent pulse, expanding antecubital haematoma or progressive neurological deficit needs immediate reduction and orthovascular action.
  • An open wound, severe skin tenting, irreducible joint or fracture-dislocation requires urgent operative review rather than repeated force.
  • Radial-head fracture with coronoid fracture and dislocation forms the terrible triad and has high recurrent instability risk.

Investigations

  1. 01
    AP and lateral elbow radiographsFirst step
    Why
    Confirm direction, radial-head and coronoid fracture and joint congruence.
    Interpretation and limitations
    Repeat after reduction; apparent relocation cannot exclude an incarcerated fragment.
  2. 02
    Full forearm and wrist radiographs
    Why
    Detect Monteggia or longitudinal radioulnar injury when examination extends beyond the elbow.
    Interpretation and limitations
    Include both adjacent joints and correlate with distal radioulnar tenderness.
  3. 03
    CT of a complex elbow
    Why
    Map radial-head, coronoid and distal-humeral fragments for operative planning.
    Interpretation and limitations
    Use after urgent reduction when possible and do not delay treatment of perfusion or skin threat.
  4. 04
    Serial neurovascular examination
    Why
    Establish median, ulnar, radial and arterial status around reduction.
    Interpretation and limitations
    Record named movements and sensory territories plus pulses and refill before and after each attempt.

Differential diagnosis

01

Distal humeral fracture

Bony crepitus and abnormal distal-humeral contour can mimic dislocation and must be recognised before forceful manipulation.

02

Olecranon fracture-dislocation

Posterior bony tenderness with disrupted ulnohumeral relationship may represent a trans-olecranon fracture-dislocation pattern requiring anatomical fixation and stability review.

03

Monteggia injury

Ulnar fracture or bowing with radial-head dislocation demands full forearm imaging and restoration of ulnar alignment.

04

Distal radioulnar injury

Wrist pain or instability with radial-head fracture suggests longitudinal forearm disruption rather than an isolated elbow lesion.

Management

01Initial careDefine simple versus complex injuryFirst stepA deformed or acutely painful elbow follows trauma.+
  1. 1Give analgesia, inspect skin and document pulses and named nerve functions.
  2. 2Obtain AP and lateral views unless urgent tissue rescue takes priority.
  3. 3Identify associated radial-head, coronoid, olecranon or forearm injury and prepare a monitored reduction.
02ReductionRestore and test safelyThe dislocation is suitable for a closed attempt.+
  1. 1Use adequate sedation or anaesthesia and a controlled familiar technique.
  2. 2Repeat neurovascular examination and obtain post-reduction images immediately.
  3. 3EscalationAssess concentricity and the stable motion arc; escalate irreducibility or recurrent subluxation.

Complications

01

Recurrent instability

Unrecognised coronoid, radial-head or collateral-ligament failure causes recurrent subluxation, apprehension, weakness and poor upper-limb function after reduction.

02

Elbow stiffness

Prolonged immobilisation, capsular scarring and heterotopic ossification can severely reduce the functional flexion-extension and forearm-rotation arc.

03

Neurovascular injury

Persistent median, ulnar or radial deficit and brachial-artery damage can cause weakness, sensation loss or ischaemia.

04

Post-traumatic arthritis

Cartilage injury, residual incongruity and radial-head comminution can produce later pain, crepitus, mechanical locking and reduced forearm rotation.

Monitoring and follow-up

  • Repeat pulses, refill and named nerve findings after reduction, splintage and swelling change.
  • Confirm maintained concentricity on post-reduction and follow-up imaging when indicated.
  • Measure flexion-extension and pronation-supination and avoid unexplained prolonged immobilisation.
  • Assess lateral pain, mechanical block and wrist or distal radioulnar symptoms.
  • Investigate recurrent giving way, locking or progressive neurological change promptly.

Special situations

Radial head is a stabiliser

It resists valgus and axial load, so excision can destabilise an elbow with ligament or interosseous-membrane injury.

The wrist completes the examination

Distal pain after radial-head fracture may reveal a longitudinal injury that elbow-only imaging misses.

Reduction is not stability

A located elbow can redislocate through a deficient coronoid and collateral complex unless the safe arc is defined.

Elbows stiffen quickly

When the joint is stable, early protected movement provides greater benefit than prolonged routine casting.

Common pitfalls

  1. 01

    Reducing without recording median, ulnar and radial nerve function first.

  2. 02

    Calling the injury simple before excluding coronoid and radial-head fracture.

  3. 03

    Ignoring wrist pain after a radial-head fracture and missing longitudinal instability.

  4. 04

    Accepting a reduction without post-procedure radiographs or stability assessment.

  5. 05

    Immobilising a stable simple dislocation for weeks until severe stiffness develops.

Painful blocked forearm rotation after reduction may indicate displaced radial-head fragment or an Essex-Lopresti-type longitudinal forearm injury.
03RecoveryMove early when stability permitsA congruent stable joint or definitively repaired complex injury is established.+
  1. 1Use brief support and begin guided flexion, extension and rotation within prescribed limits.
  2. 2Treat radial-head fracture according to mechanical block and associated stability.
  3. 3Monitor stiffness, instability, nerve recovery and wrist symptoms through follow-up.
Key medicines and prescribing safety1 treatment · regimens, roles and cautions+
Provides baseline analgesia supporting examination and early movement.

Paracetamol for adult elbow pain

Give 500 mg to 1 g orally when required, separated by at least 4 hours and limited to four doses or 4 g in 24 hours.

Reduce the limit for low body weight or hepatic risk and total all combination medicines.