History

• 21 yo male presents after ground level fall, he landed on his outstretched R hand aka "FOOSH" (fall on outstretched hand)
• He immediately felt pain at the elbow and heard a pop
• He denies any numbness or weakness of the hand
• Denies wrist or shoulder pain
• Denies striking head or LOC, and has no HA or neck pain

Physical exam

• HEENT: No evidence of trauma
• C-spine: no tenderness to palpation
• Pulm: Lungs clear
• Cardio: No murmurs
• Abd: Soft, nontender
• Neuro: Intoxicated but otherwise no abnormalities
• Extremities: obvious deformity of R elbow. No tenderness over R shoulder, able to abduct. No tenderness at wrist, normal flexion/extension, no snuffbox tenderness. Radial pulse is 2+, and cap refill is <2s in all digits

Ddx:

• A FOOSH is a classic mechanism for many orthopedic injruies including: scaphoid fracture, scapho-lunate ligament injury, distal radius fracture aka "Colle's fracture," elbow dislocation if elbow flexed, humeral neck fracture, and others

Plain films:

Interpretation: Posterior dislocation of R elbow. No associated fractures

Management

• An intra-articular injection of 1/2 1% lidocaine 1/2 0.25% bupivicane was used for analgesia
• See how to perform this invaluable technique here
• Reduction was performed with in-line traction combined with supination and elbow flexion 
• For a demonstration check out this video from the incomparable YouTube celebrity Dr. Mellick

Outcome and Teaching Points

Post reduction films:

Interpretation: Satisfactory reduction of elbow, no associated fractures

• Post-reduction no neurovascular compromise noted
• Patient placed in posterior long arm splint and sling
• Discharged with instructions to follow with ortho in a week

Tips:

• Consider an intra-articular injection of local anesthestics as an alternative to the much more labor-intensive procedural sedation
• Simple longitudinal traction with elbow in flexion is usually successful to reduce these injuries
• Adding supination to traction may help with reduction
• Be mindful of ancillary injuries at the wrist and shoulder with this type of injury