Elbow Injuries and Fractures

See also forearm fractures (deals with Monteggia's fractures).

• Radial head fracture is the commonest fracture around the elbow joint in adults, whereas radial neck fractures occur more commonly in children.
• Most commonly due to fall on outstretched arm.
• Patient presents with swelling over the lateral elbow with limited range of motion, particularly forearm rotation and elbow extension ± elbow effusion and bruising. Pain increased with passive rotation.
• Most reliable clinical sign is point tenderness over radial head.
• Needs careful assessment for nerve and vascular involvement, especially with brachial artery, median and ulnar nerves.
• Important to detect a mechanical blockage of motion from displaced fracture fragments. 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, may be acute longitudinal radioulnar dissociation with disruption of the distal radioulnar joint.

Investigations

• AP and lateral X-ray views of elbow are usually sufficient.
• Findings may be quite subtle and only clue may be fat pad sign (triangular radiolucent shadows anterior and posterior to 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 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 elbow in long arm posterior splint with elbow at 90°.
• In non-displaced fractures, remove posterior splint and replace with 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.
• May be associated ulna shaft fracture (equivalent to adult Monteggia fracture).
• US or MRI may be needed to confirm the diagnosis.

• Low energy fractures occur most commonly in the elderly and result from indirect trauma due to sudden pull of triceps and brachioradialis muscles.
• In younger patients usually follow direct blow to the point of the elbow and are often comminuted and may have associated ulna shaft fracture.
• Patient presents with swelling and tenderness over the olecranon with haemarthrosis and limited range of motion.
• An inability to extend the elbow against gravity indicates dysfunction of triceps lever.
• Need to check for ulnar nerve damage and examine distal pulses.
• True lateral X-ray of elbow should reveal the fracture.

Management

• Immobilise elbow in long arm posterior splint with elbow in 60–90° flexion, well moulded posteriorly.
• Support arm with collar and cuffs or 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 using a sling or removable posterior splint for comfort.
• Flexion and extension exercises after 2 weeks.

• Associated with elbow dislocation in about 40%.
• Patients present with tenderness over antecubital fossa and swelling about the elbow.
• Check strength of radial pulse with elbow at 90°.
• Lateral X-ray of elbow.
• Image of coronoid fracture.

Management

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

• Supracondylar/transcondylar – most are extension-type injuries from fall on outstretched arm.
• Transcondylar fractures are more common in elderly.
• Supracondylar fractures are more common in children.
• Patient usually presents with elbow swelling and pain.
• Careful examination for neural or vascular involvement due to risk of damage to brachial artery and nerve.
• Marked swelling of 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 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 elbow in long arm posterior splint with elbow at 90° degrees forearm in neutral rotation.
• Check distal pulses after splint applied and if absent, extend elbow to point where pulses return.
• Frequent checking of neural and vascular function essential during first 7–10 days, ice and elevation are important in reducing swelling.
• Re-examine within 24–48 hours.
• After 2 weeks, patients should remove splint and perform gentle exercises and continue using splint for approx. 6 weeks, then start vigorous exercises.

• T- or Y-shaped fractures with varying displacement between the condyles and the humerus.
• Commonly caused by direct or indirect blow to elbow.
• Patient usually presents with marked tissue swelling holding their forearm in pronation.
• Injured forearm may appear shortened.
• May feel crepitus of movement 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.

• Lateral condyle fractures are more common than medial.
• Lateral fractures are usually due to direct impact on a flexed elbow.
• Medial due to impact to olecranon with flexed elbow.
• Sudden adduction or hyperextension may also cause these fractures.
• Patients usually present with swelling, limited range of movement and tenderness over 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 elbow at 90°.

• Fracture involving the distal humeral articular surface.
• Usually fall onto outstretched hand or direct trauma.
• 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.

• Very common especially in young people undertaking sport.
• Often due to fall onto extended elbow.
• Those without fracture are termed simple whereas dislocations with fracture are termed complex.
• Classified according to position of ulna in relation to humerus after injury.
• Often associated with injury to brachial artery and nerve so full examination of distal pulses, median and ulnar nerve function.
• Patient usually presents with severe pain with elbow flexed and swelling and deformity apparent.
• AP and lateral X-rays of elbow to confirm dislocation and exclude fractures.
• Image of lateral view of posterior dislocation.

Management

• Prompt reduction 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 elbow is flexed.
  • May need downward pressure on proximal forearm.
  • If this fails, place patient face down with elbow hanging off side of table and place small pillow under the humerus just proximal to the elbow joint and 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 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 elbow in posterior splint with elbow at 90°.