Summary Elbow Dislocations in the pediatric population usually occur in older children (10-15 years) and can be associated with elbow fractures such as medial epicondyle fractures. Diagnosis can be made with plain radiographs of the elbow. Treatment is usually closed reduction followed by brief immobilization. Open reduction is indicated for dislocations associated with a medial epicondyle fracture with an incarcerated fragment. Epidemiology Incidence 3-6% of all pediatric elbow injuries Dffemographics male:female = 3:1 most common in 10-15 year olds very rare in younger children < 3 years old Etiology Pathophysiology mechanism of injury fall onto an outstretched hand pathoanatomy posterior dislocation hyperextension, valgus stress, and supination anterior dislocation a direct posterior to anterior force on a flexed elbow relatively small coronoid process in children cannot resist distal and posterior displacement of ulna Associated conditions traumatic avulsion of the medial epicondyle medial epicondyle fractures are the most common associated fracture incarcerated intra-articular bone fragment may block reduction fractures of proximal radius, olecranon and coronoid process neurovascular injury brachial artery and median nerve may be stretched over displaced proximal fragment ulnar nerve at risk with associated medial epicondyle avulsions most common neuropraxia congenital dislocation of radial head Classification Anatomic classification based on the position of the proximal radio-ulnar joint in relation to the distal humerus includes posterolateral (most common) posteromedial anterior (rare) divergent Presentation Symptoms painful and swollen elbow attempts at motion are painful and restricted Physical exam inspection elbow held in flexion forearm appears to be shortened from the anterior and posterior view palpation distal humerus creates a fullness within the antecubital fossa essential to perform neurovascular examination assess for brachial artery and median/ulnar nerve injury Imaging Radiographs required views AP and lateral radiograph of elbow comparison radiographs of the contralateral elbow may be helpful findings loss or radiocapitellar and ulnohumeral relationship but maintained radial and ulnar relationship look for fractures of medial epicondyle, coronoid, proximal radius "elbow dislocation" in very young (<3 years old) most likely represents a distal humerus physeal separation and raises concern for nonaccidental trauma Treatment Nonoperative closed reduction, brief immobilization with early range of motion indications dislocation that remains stable following reduction indicated in the majority of cases reduction technique (see below) should be addressed promptly as reduction should not be delayed brief immobilization immobilization should be minimized to 1- 2 weeks to minimize risk of stiffness early therapy encourage early active range of motion Operative open reduction indications open dislocation incarcerated medial epicondyle or coronoid process in the joint failure to obtain or maintain an adequate closed reduction significant joint instability (rare) Technique Closed reduction technique posterior dislocations supine closed reduction performed with the elbow flexed in forearm supination using gradual traction prone forearm hanging from table and anterior directed force on olecranon anterior dislocations inline traction to distal forearm with a posteriorly directed force on the forearm and an anteriorly directed force on the distal humerus post-reduction films should be reviewed to rule out presence of entrapped bone fragment must locate medial epicondyle on post-reduction radiographs to ensure it is not within the joint Open reduction approach depends on reason for blocked reduction elbow medial approach indicated if medial epicondyle avulsion with incarcerated fragment is blocking reduction Complications Stiffness most commonly loss of terminal extension due to prolonged immobilization Heterotopic ossification vigorous reduction increases risk Neurologic injuries usually transient median nerve injury may occur due to nerve entrapment ulnar nerve most commonly affected if associated medial epicondyle fracture occurs Vascular injury brachial artery may be injured (rare) Compartment syndrome excessive swelling and immobilization in hyperflexion Chronic instability (recurrent dislocations) associated with coronoid and radial head fractures