Posterior elbow dislocation (PED) occurs when the radius and ulna are strongly driven behind the humerus.
Specifically, the olecranon is displaced into the olecranon fossa and the trochlear is displaced above the coronoid. PED is classified as uncomplicated or complex and staged according to severity. 
PED is the most common type of joint dislocation in children under 10 years of age. 
In adults, they are the second most commonly dislocated joint after shoulder dislocations. 
Elbow dislocations affect 6 to 7 in 100,000 people each year.  Approximately 90% of elbow dislocations are orientationally classified as posterolateral or posterolateral, and are more commonly seen in the nondominant upper extremity. 
Typically, an elbow dislocation is caused by a hyperextension injury from a traumatic fall onto an outstretched hand.  However, recent studies have shown that axial compression of the elbow flexion-valgus stress and supination of the forearm causes the ulna to Distal humerus.  If there was insufficient valgus/varus traction on the joint at the time of trauma, coronoid fractures are likely to occur as well. 
The most common dislocations are associated with damage or tearing of the anterior capsule.  
PEDs can be classified as simple or complex. 
- Simple dislocations are classified as dislocations without fractures.
- Complex dislocations have associated fractures. 
- Fractures may be present in the radial head coronoid olecranon humeral condyle or capitellum .
- These fractures may result in rupture of the medial collateral ligament (MCL), lateral collateral ligament (LCL), or interosseous membrane. 
- The “terrible triad” is a term used to describe severe complex dislocations with intraarticular fractures of the radial head and coronoid.  Staging of elbow dislocations depends on disruption of the following stabilizers: ulnohumeral joint MCL and LCL. 
The clinical presentation may include:
- Popping sensation on immediate injury
- Reduced AROM
- Swelling – the olecranon may protrude, forming a depression over the distal triceps 
- Joint line tenderness on palpation
- If ligamentous injury persists, recurrent dislocations may occur 
Valgus stress was obtained for radiographs in anterior, posterior, and lateral views of the PED for diagnosis. 
Table 1 below: describes other injuries that should be considered when PED is suspected.
Diagnosis Cause Findings Posterolateral rotational instability Insufficient ulnar LLC Valgus instability Positive lateral pivot shift test Recurrent dislocation Associated fracture Traumatic force through radial head humeral condyle olecranon or Microcephaly Radiology Diagnosis Fracture Visual Tenderness. Positive Elbow Extension Compartment Syndrome Fracture Swelling Casting Trauma Pain Disproportionate to Injury Pulseless Pale Paresthesias Paralysis Complex Regional Pain Syndrome (CRPS) Unknown After Persistent Pain Injury Swelling Hypersensitivity Skin Color/Texture Changes Decreased ROM Weakness
A physical examination should include:
- Observation – specifically deformities
- Vascular Screen – Palpation of Brachioradial and Ulnar Arteries
- Neuromuscular screening – dermatomes, sarcomeres, and reflexes, including upper extremity nerve tone testing (if tolerated by patient)
- Palpation – Palpation of elbow-related fractures is essential. Elbow extension sign can be used to rule out fracture.
- Muscle testing
- Ligament Integrity Tests – Varus and Valgus Stress Tests Lateral Pivot Shift Tests/Worry Tests (Posterolateral Rotational Instability Tests).
Before surgery is considered, research suggests that reduction under local or general anesthesia is the mainstay of treatment for PED. 
X-rays are indicated when unresponsive to care after 4 weeks of conservative treatment or when non-mechanical pain persists for more than 4 weeks or when there is significant limitation of motion. 
Before deciding to address these factors surgically, the following factors need to be considered:
- Irreducible dislocation
- Instability (recurrent instability may indicate ligament repair 
- Elbow stiffness
- Neuro-vascular injury
The most common surgical options include open surgery and resection or closed arthroplasty.  Open surgery is more likely when fractures are involved, including:
- Ulnar nerve release,
- Humeroulnar reduction
- Humeroradial reduction,
- Lengthen the Triceps with Speed’s Program
- Wires and/or screws placed in the olecranon are used to stabilize the joint. 
- Ligamentus repairs with sutures
Once the procedure is complete, the patient is usually immobilized, with time frames varying by individual and surgeon agreement.  Some patients may be allowed to actively move the elbow immediately postoperatively, but this is up to the surgeon. 
A hinged brace immobilizer plaster cast and sling is used to hold the elbow in a position of approximately 70-80o of flexion and slight pronation.
While the approach to conservative management of PED may vary depending on the degree of tissue involvement, there are some key factors to consider throughout the clinical decision-making process. The severity of PED can occur on a continuum; therefore, treatment must also vary.
Depending on the orthopedic intervention, treatment can vary from aggressive immediate AROM to traditional cast immobilization for a few days.   If the fracture is secondary to dislocation, the intra-articular bone fragment and fracture location may determine treatment. 
After typical reduction without fracture:
- Immobilization: Typically involves the use of a posterior splint  for three days to three weeks with the elbow in 45-90o of flexion.  Wrist and shoulder function should be maintained through ROM and strengthening exercises throughout the immobilization phase.  Inflammation is a Commonly seen after PED, can be resolved using PRICE protocol. 
- Following the immobilization phase, physical therapy begins with gentle AROM and PROM exercises targeting the entire upper extremity in a pain-free range. 
- When pain is no longer an obstacle to treatment, functional progressive resistance training should be implemented to improve upper extremity muscle strength and endurance. 
- Goals of treatment in the later stages of rehabilitation include achieving full ROM and strength capability of the entire affected arm, suppressing pain, and restoring functional ability to pre-injury levels. 
- Patients are able to return to functional activity at around 12 weeks and sports at around 6 months. 
Complications post reduction
Prolonged immobilization may have adverse effects, including increased pain perception in flexion contractures and increased duration of disability, all of which prolong the rehabilitation process. 
Physiotherapists should be aware of needle site infections when treating patients with postoperative PED. 
Although full extension should be the goal of rehabilitation, care must be taken to protect the vulnerable elbow and avoid hyperextension. It is important to be careful during passive mobilization and ROM.
American Academy of Orthopedic Surgeons
Clinical Bottom Line
As the elbow is one of the more commonly dislocated joints , it is imperative that the physical therapist be aware of its complications and the best evidence for its treatment.
It is important to explore the severity and degree of complications associated with each PED as this determines the patient’s prognosis. Patients with uncomplicated PED who are reduced early usually have good outcomes.
In most cases, unstable and degenerative joint disease may be present. 
Overall, the best treatment for PED is an initial short-term limited ROM (usually two weeks or less), followed by early mobilization, including progression from PROM to AROM and functional enhancement. This allows for a quicker return to work and/or sports. 
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