Elbow Injuries and Fractures

oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

The humerus of the upper arm and the paired radius and ulna of the forearm meet to form the elbow joint, a hinge joint in the upper arm. The bony prominence at the tip of the elbow is the olecranon process of the ulna. The antecubital fossa lies over the anterior aspect of the elbow.

Injuries to the elbow are common and often accompanied by injury to shoulder or wrist joints. It is important to assess injuries promptly and accurately taking into account age and the mechanism of injury, particularly because of the risk of accompanying vascular involvement.

In addition to injuries listed in the table below, see also separate articles forearm injuries and fractures (deals with Monteggia's fractures), pulled elbow (nursemaid's elbow), tennis elbow and olecranon bursitis.

There are a variety of possible injuries because of the presence of three bones and the variety of mechanisms of injury.

Mechanism of injury in elbow fractures and dislocation
Radial head and neck fractures Fall on to an outstretched hand
Olecranon fractures
  • Elderly - indirect trauma by pull of triceps and brachioradialis
  • Children - direct blow to elbow
Fractures of the coronoid process Fall on to extended elbow as for elbow dislocation
Fractures of the distal humerus Fall on to extended outstretched hand
Intercondylar fractures Direct or indirect blow to elbow
Condylar fractures Direct blow to flexed elbow
Capitellum fracture Fall on to outstretched hand or direct trauma
Elbow dislocation
  • Fall on to extended elbow
  • Common in sport in the young

Mechanism of injury

These are most commonly caused by a fall on to an outstretched arm. Radial head fracture is the most common fracture around the elbow joint in adults, whereas radial neck fractures occur more commonly in children.

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Clinical features

  • The patient presents with swelling over the lateral elbow with limited range of motion, particularly forearm rotation and elbow extension ± elbow effusion and bruising. Pain is increased with passive rotation.
  • The most reliable clinical sign is point tenderness over the radial head.
  • Needs careful assessment for nerve and vascular involvement, especially with brachial artery, median and ulnar nerves.
  • It is important to detect a mechanical blockage of motion from displaced fracture fragments. This often needs aspiration of the haemarthrosis with instillation of local anaesthetic for pain relief.
  • Presence of severe crepitation or complete blockage of motion for full extension and flexion shows presence of displaced fragments.
  • If there is significant wrist pain and/or central forearm pain, there may be acute longitudinal radioulnar dissociation with disruption of the distal radioulnar joint.

Investigations

  • AP and lateral X-ray views of the elbow are usually sufficient.
  • Findings may be quite subtle and the only clue may be the fat pad sign (triangular radiolucent shadows anterior and posterior to the distal humerus on lateral X-ray, indicating haemarthrosis and displacement of intra-articular fat pad - often associated with intra-articular skeletal injury).
  • Image of elbow fat pad sign. Images of radial head fractures.

Management

  • Refer for urgent surgical treatment if there is elbow fracture, dislocation or evidence of nerve or vascular involvement.
  • Complex fractures require open reduction and internal fixation.
  • Otherwise, give sufficient analgesia and consider joint aspiration and instillation of anaesthetic as described above (usually in expert hands).
  • Immobilise the elbow in a long arm posterior splint with the elbow at 90°.
  • In non-displaced fractures, remove the posterior splint and replace with a sling for comfort only, monitor for displacement and institute active range of movement exercises, including rotation, flexion and extension at least 3-4 times daily.

In children

  • Can be difficult to diagnose, as radial head ossification does not occur until age 4.
  • There may be an associated ulnar shaft fracture (equivalent to adult Monteggia's fracture).
  • Ultrasound or MRI scanning may be needed to confirm the diagnosis.

Mechanism of injury

These are low-energy fractures which occur most commonly in the elderly and result from indirect trauma caused by a sudden pull of the triceps and brachioradialis muscles.
However, in younger patients, olecranon fractures usually follow a direct blow to the point of the elbow and are often comminuted, and there may be an associated ulnar shaft fracture.

Clinical features

  • The patient presents with swelling and tenderness over the olecranon with haemarthrosis and limited range of motion.
  • There is an inability to extend the elbow against gravity, indicating dysfunction of the triceps lever.
  • There is a need to check for ulnar nerve damage and examine distal pulses.
  • True lateral X-ray of the elbow should reveal the fracture.

Management

  • Immobilise the elbow in a long arm posterior splint with the elbow in 60-90° flexion, well moulded posteriorly.
  • Support the arm with collar and cuffs or a standard arm sling.
  • Refer displaced fractures for surgery. In non-displaced fractures, splint for 5-7 days, remove and repeat X-ray to confirm non-displacement.
  • If still stable, gentle supination and pronation exercises are appropriate, using a sling or removable posterior splint for comfort.
  • Flexion and extension exercises after 2 weeks.

Mechanism of injury

The mechanism of injury is as for elbow dislocation and such fractures are associated with elbow dislocation in about 40% of cases

Clinical features

  • Patients present with tenderness over the antecubital fossa and swelling about the elbow.
  • Check strength of the radial pulse with the elbow at 90°.
  • Lateral X-ray of the elbow to show coronoid fracture.

Management

  • Non-displaced fractures should be immobilised in a long arm posterior splint with the elbow at 90° and the forearm in full supination. After 3 weeks, start active range of movement exercises using a sling for comfort.
  • Displaced fractures or those involving >50% of process need surgical repair.

Mechanism of injury

  • Supracondylar/transcondylar - most are extension-type injuries from a fall on to an outstretched arm.
  • Transcondylar fractures are more common in the elderly.
  • Supracondylar fractures are more common in children.

Clinical features

  • The patient usually presents with elbow swelling and pain.
  • Undertake careful examination for neural or vascular involvement due to risk of damage to the brachial artery and nerve.
  • Marked swelling of the forearm or palpable induration of forearm flexors, with pain on passive extension of the fingers, suggests acute volar compartment syndrome requiring emergency fasciotomy.
  • AP and lateral X-rays of the elbow.
  • Images of transcondylar fracture and its repair.

Management

  • All but non-displaced or minimally displaced fractures without neural or vascular involvement should be referred for surgical repair.
  • Immobilise the elbow in a long arm posterior splint with the elbow at 90° to the forearm in neutral rotation.
  • Check distal pulses after the splint has been applied and, if absent, extend the elbow to the point where pulses return.
  • Frequent checking of neural and vascular function is essential during the first 7-10 days, and ice and elevation are important in reducing swelling.
  • Re-examine within 24-48 hours.
  • After 2 weeks, patients should remove the splint and perform gentle exercises, continuing to use a splint for approximately 6 weeks, and then starting vigorous exercises.

These are T- or Y-shaped fractures with varying displacement between the condyles and the humerus.

Mechanism of injury

Commonly caused by a direct or indirect blow to the elbow.

Clinical features

  • The patient usually presents with marked tissue swelling holding their forearm in pronation.
  • The injured forearm may appear shortened.
  • Crepitus of movement may be felt when condyles are pressed together.
  • AP and lateral views of intercondylar fracture.

Management

  • Most fractures require surgery because they are displaced.
  • Refer for orthopaedic opinion.
  • Rarely, non-displaced fractures can be treated similarly to non-displaced supracondylar fractures, as above.

Mechanism of injury

  • Lateral condyle fractures are more common than medial.
  • Lateral fractures are usually due to direct impact on a flexed elbow.
  • Medial fractures are due to impact to the olecranon with flexed elbow.
  • Sudden adduction or hyperextension may also cause these fractures.

Clinical features

  • Patients usually present with swelling, limited range of movement and tenderness over the injured condyle.
  • Crepitus with motion is frequently present.
  • AP and lateral X-rays reveal a widened intercondylar distance and there may be displaced fracture fragments.

Management

  • Aspiration of joint haemarthrosis relieves discomfort.
  • Displaced fractures require surgical correction.
  • Undisplaced fractures can be treated with a long arm posterior splint with the elbow at 90°.

Mechanism of injury

These fractures are usually caused by a fall on to the outstretched hand or by direct trauma.

Clinical features

  • These fractures involve the distal humeral articular surface.
  • Present with anterior elbow pain and effusion.
  • Lateral and AP radiography usually reveals the fracture.
  • Images of capitellum fracture.
  • Management: undisplaced fractures may be splinted but more usually they are displaced and require surgical fixation.

Elbow dislocation is very common especially in young people undertaking sport.

Mechanism of injury

  • Often due to a fall on to an extended elbow.
  • Those without fracture are termed simple, whereas dislocations with fracture are termed complex.
  • They are classified according to position of the ulna in relation to the humerus after injury.

Clinical features

  • Often associated with injury to brachial artery and nerve, so undertake full examination of distal pulses, median and ulnar nerve function.
  • The patient usually presents with severe pain with the elbow flexed and swelling and deformity apparent.
  • AP and lateral X-rays of the elbow to confirm dislocation and exclude fractures.
  • Image of lateral view of posterior dislocation.

Management

  • Prompt reduction is essential. This is usually performed under IV sedation and with adequate analgesia.
  • Posterior dislocation:
    • First try countertraction on the humerus while applying longitudinal traction on the wrist and forearm.
    • Continue distal traction as the elbow is flexed.
    • May need downward pressure on the proximal forearm.
    • If this fails, place the patient face down with the elbow hanging off the side of the table and place a small pillow under the humerus just proximal to the elbow joint; hang a 2½-10 kg weight from the wrist or apply gentle longitudinal traction.
    • Usually reduces within several minutes but may need forward pressure on the olecranon.
  • Anterior dislocation:
    • Basically the reverse of the above, applying posterior and downward pressure to the forearm whilst applying anterior pressure from behind to the distal humerus.
    • After reduction, test joint mobility and stability and check neural and vascular function. Repeat X-ray and immobilise the elbow in a posterior splint with the elbow at 90°.

Further reading & references

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Colin Tidy
Current Version:
Last Checked:
16/07/2010
Document ID:
2091 (v22)
© EMIS