Orthopaedics — Initial Management of Elbow Fracture-Dislocation
A 32-year-old man falls onto his outstretched right hand while playing football. His elbow is swollen and held flexed, with a prominent olecranon posteriorly. The skin is intact, radial pulse is palpable, and hand sensation and finger movement are normal. Radiographs show a posterior elbow dislocation with a displaced radial head fracture. What is the most appropriate initial management?
- A.Closed reduction under procedural sedationCorrect
- B.Immediate open reduction and internal fixation
- C.Above-elbow backslab in the presenting position
- D.Primary radial head excision
Explanation
A dislocated elbow should be reduced promptly, whether or not there is an associated fracture. Prolonged dislocation stretches the brachial artery and the median and ulnar nerves, increases swelling and pain, and makes later reduction harder. With the neurovascular status documented, closed reduction under procedural sedation is performed using in-line traction with the elbow slightly flexed and the forearm supinated, followed by flexion while the olecranon is pushed forward. Neurovascular status is then rechecked, stability is assessed through a range of movement, and post-reduction radiographs and usually CT are obtained. Posterior dislocation with a radial head fracture is commonly accompanied by a coronoid fracture, forming the so-called terrible triad, which is unstable and generally requires operative fixation or replacement of the radial head, coronoid repair and lateral ligament reconstruction. That surgery is planned as a semi-elective procedure after the joint has been relocated and imaged, not as the first step in the emergency department. Splinting in the dislocated position leaves the joint unreduced, and excising the radial head without restoring it removes a key stabiliser. An open dislocation or an irreducible joint goes directly to theatre.
Why each option
- A.
- Correct. Prompt closed reduction relieves tension on neurovascular structures and allows proper post-reduction imaging to plan definitive treatment of the fracture.
- B.
- Operative fixation is often needed for these injuries but follows reduction and CT planning; immediate surgery is reserved for open or irreducible dislocations.
- C.
- Splinting the elbow still dislocated leaves ongoing stretch on the brachial artery and nerves, so the joint must be reduced before immobilisation.
- D.
- Excision removes an important secondary stabiliser and risks recurrent instability; a comminuted radial head in this injury is replaced rather than excised.
Reference: AAOS OrthoInfo — Elbow Dislocation (2023); UpToDate — Elbow dislocation in adults (2025); Rockwood and Green's Fractures in Adults, 10th ed. (2024)
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