What is your diagnosis?

Posterior elbow dislocation 

• Pearl: Elbow dislocations are the most common joint dislocation in pediatric patients and second most common in adults (shoulder dislocation being the first). Among these, posterolateral dislocations are the most common type. Multiple ligaments are often injured or torn in this injury, with the lateral collateral ligament being the most common [1].

What is the possible “terrible triad” associated with this injury?

Elbow dislocation with radial head fracture and coronoid fracture

• Pearl: It is important to get good lateral and anteroposterior images of the elbow for better evaluation and identification of fractures associated with an elbow dislocation. Closed reduction is still a good idea, but most of these cases will ultimately require surgical management [2].

What is your management in the ED?

Evaluate for evidence of a complex dislocation, such as open wounds or neurovascular compromise. If none, you can proceed with closed reduction in the ED. Have an assistant hold the forearm in flexion at 30 degrees and have them hold counter traction. Supinate the arm and apply traction to the distal forearm while placing direct pressure on the olecranon. Once reduction is achieved, place them in a long arm posterior mold splint with the elbow at least at 90 degrees of flexion. 

What is your disposition? Does this need urgent orthopedics consultation?

If closed reduction is successful, the patient can discharge home with orthopedic surgery follow up within one week. For a simple dislocation, orthopedic surgery does not typically need to be involved in the ED. However, if there is evidence of neurovascular compromise, an open fracture, or the elbow is irreducible, urgent orthopedics consultation will be necessary.