Elbow dislocation and radial-head fracture

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.

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.