AUTHOR AND EDITOR INFORMATION

Section 1 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

INTRODUCTION

Section 2 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Background

Elbow fractures are commonly encountered in the acute care setting. Injury patterns for children and adults are quite different. Fractures of the elbow include extra-articular and intra-articular fractures. Extra-articular fractures include intercondylar fractures, supracondylar fractures, epicondylar fractures, and condyle fractures.  Intra-articular fractures include trochlea and capitellum fractures, radial head, proximal ulnar fractures.¹ The examining physician must perform a thorough neurovascular examination with all suspected elbow fractures; recognize subtle fracture patterns; provide adequate immobilization; and assess whether fractures require admission, immediate orthopedic evaluation, or less urgent referral.

Anatomy

The elbow is a hinge joint composed of 3 bones: the ulna, the radius, and the humerus. The 3 main articulations of the elbow are (1) the humeroradial articulation, which is formed by the radial head and the capitellum of the humerus; (2) the humeroulnar articulation, which is formed by the ulnar notch and the trochlea of the humerus; and (3) the superior radioulnar articulation, which is formed by the proximal part of the ulna and the radius. All articulations are contained in one synovial-lined capsule, which typically encases a hemarthrosis following injury.
 
Two main movements occur at the elbow: flexion and extension, which occurs primarily at the humeroulnar articulation, and pronation and supination, which occurs primarily at the radioulnar articulation. 

Pathophysiology

Fracture patterns vary widely due to the mechanism of injury as well as the age of the patient. Direct trauma or a fall onto an outstretched hand is responsible for most elbow fractures. Neurovascular injury is a common complication of elbow fractures. The brachial artery is the most commonly injured artery and is seen especially in supracondylar fractures. The median nerve is the most commonly injured nerve, which is often is due to a displaced supracondylar humerus fracture.

Extra-articular fracture patterns

Intercondylar fractures (see Media file 1)

• Intercondylar fractures occur when the condylar fragments are separated.
• They are much more common in adults than in children. Any distal humerus fracture in adults is more likely intercondylar than supracondylar.
• The mechanism is force directed against the posterior elbow such as a fall onto a flexed elbow, driving the olecranon against the humeral articular surface separating the condyles.
• Fractures are often a T or Y shaped fracture of the distal humerus.
• Treatment is often complicated and requires anatomic reduction either open or closed.²

Supracondylar fractures (see Media file 2)

• The supracondylar fracture is the most common pediatric elbow fracture (60%) with the average age of 6.7 years and rarely seen after age 15 years.³
• Complications include injuries to nerves (the median, radial, and anterior interosseous nerves are the most commonly injured).
• Most deficits are neurapraxias that resolve with conservative management
• Motor function usually recovering in 7-12 weeks while sensory function usually recovers in 6 months.⁴
• Vascular injuries should always be suspected with supracondylar fractures.
• Ten percent of children have temporary loss of the radial pulse due to swelling and not direct arterial injury.⁵
• The most common complication for supracondylar fractures are cubitus varus or “gunstock deformity,” which is a loss of the carrying angle and results in more of a cosmetic disability rather than a functional disability (see Media file 9).
• Although rare (<0.5%), the most serious complication is Volkmann ischemic contracture due to postfracture swelling, producing increased pressure in the forearm compartment leading to muscle and nerve necrosis and eventual replacement by fibrotic tissue producing contracture.⁶
• In general, an orthopedic consultant best handles decisions regarding reduction of significantly angulated and displaced fractures.
• If neurovascular structures are compromised, the emergency physician may need to apply forearm traction to reestablish distal pulses.
• If pulse is not restored with traction, emergent operative intervention for brachial artery exploration or fasciotomy is indicated.
• In children, nondisplaced, nonangulated fractures can be splinted (elbow in 90° of flexion); angulated fractures require reduction and splinting; and displaced fractures (see Media file 3) require reduction and percutaneous pinning on an urgent basis within 12-24 hours.
• In adults, supracondylar fractures generally require surgery.

Extension-type

• Ninety-five percent of supracondylar fractures are of the extension-type and are displaced posteriorly due to an extension force.
• • Type I fractures - Undisplaced
  • Type II fractures - Displaced with posterior cortex still intact
  • Type III fractures - Displaced with both anterior and posterior cortex disrupted
• Management of type I fractures consists of immobilization with the elbow in flexion, while type II and II are generally treated by closed reduction followed by pin fixation.
• Type III fractures have significant displacement and have a high incidence of neurovascular injury and therefore require urgent orthopedic consultation in the ED.
• Open reduction is reserved for vascular insufficiency with a probable entrapped brachial artery in the fracture site or an irreducible fracture.

Flexion-type

• Five percent of supracondylar fractures are of the flexion-type and have anterior displacement due to a flexion force.
• The mechanism usually involves direct anterior force with anterior displacement of the distal fragment.
• Open fractures are relatively common due to the direct force.
• • Type I fractures -  Undisplaced
  • Type II fractures - Displaced with anterior cortex still intact
  • Type III fractures - Displaced with both anterior and posterior cortex disrupted and distal fragment migrants anteriorly and proximately
• Treatment of type I fractures is simple immobilization in the flexed position.
• Treatment of type II and III fractures should be referred to an orthopedist emergently and is often reduced to an extension position and requires surgical management.⁵

Epicondyle fractures

• Fractures of the epicondyles are considered extra-articular.

Medial epicondyle fracture (see Media file 4)

• Medial epicondyle fractures are usually in children as an avulsion type injury
• Mechanisms include posterior elbow dislocation, throwing a baseball (Little League elbow), or a direct blow.
• Edema and pain over the medial elbow is common.
• Nondisplaced or minimally displaced medial epicondyle fractures are treated nonoperatively.
• Fragment displacement greater than 1 cm or valgus instability are often treated with internal fixation.
• Rarely, entrapment of the medial epicondyle can occur between the trochlea and the coronoid process of the ulna; this can be mistaken for the ossification center of the trochlea.
• ED management consists of immobilization of the forearm in flexion and pronation and the wrist in flexion.

Lateral epicondyle fracture

• Lateral epicondyle fracture is very rare and is usually due to an avulsion fracture.
• Fracture of the lateral humeral epicondyle can be mistaken for the radiolucency of the epiphysis.⁷
• Treatment is immobilization with the elbow flexed to 90 degrees and the forearm in supination.⁷

Condyle fractures

Medial condyle fracture

• Medial condyle fracture is rare and is usually found in children.
• The mechanism is a fall on outstretched hand or excessive valgus stress.
• This injury is often confused with medial epicondyle fractures.
• Minimally displaced fractures are usually casted, whereas fractures with greater displacement usually require open or closed reduction with pin fixation.⁷

Lateral condyle fracture (see Media file 5)

• Lateral condyle fracture is usually found in children and is the second most common pediatric elbow fracture.⁸
• The mechanism is a blow to the lateral elbow or from varus stress.
• Minimally displaced fractures are usually casted, whereas fractures with greater displacement usually require open or closed reduction with pin fixation.⁸

Intra-articular fracture patterns

Trochlea fracture

• Isolated trochlea fractures are rare and are usually associated with other elbow injuries.
• Nondisplaced fractures are usually managed with a posterior splint, whereas displaced fractures require surgical management.⁷

Capitellum fracture

• Isolated capitellum fractures are rare as they often occur in posterior elbow dislocations or with radial head fractures.
• They are usually due to a fall on an outstretched hand.
• Surgical repair is often indicated.

Radial head fractures (see Media file 6)

• Radial head fracture is the most common of all fractures of the elbow and  associated injuries are common.
• The mechanism is usually a fall onto an outstretched hand.
• Radial head fracture is characterized by point tenderness at the radial head (located along the lateral aspect of the elbow) and pain with pronation/supination.
• A specific associated injury, the Essex-Lopresti lesion occurs when the radial-ulnar interosseous membrane is disrupted, causing distal radioulnar joint dissociation.
• Careful examination of radiographs is important because fractures may be subtle.
• For nondisplaced fractures, a sling with the elbow in flexion is usually adequate.
• With displaced radial head fractures, patients can be placed in a posterior long-arm splint with the elbow in 90° of flexion and the forearm in full supination and placed in a sling for comfort.

Olecranon fractures (see Media file 7)

• The mechanism is usually a direct blow or a fall onto an outstretched hand.
• The fracture line is usually transverse, passing into the trochlear notch.⁷
• Patients demonstrate an inability to extend the elbow actively, along with point tenderness at the olecranon.
• Ulnar nerve injury is common.
• Patients can be placed in a well-padded, long-arm posterior splint with the elbow in 70° of flexion and the forearm neutral with respect to pronation/supination.
• Nondisplaced fractures are usually managed conservatively, whereas all others often require surgical repair.

Age

• Fracture patterns vary markedly among different age groups.
• Supracondylar fractures are the most common elbow fracture in children because of the relative strength of surrounding ligaments in comparison to bone.
• Radial head fractures are the most common elbow fracture in adults.

CLINICAL

Section 3 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

History

Mechanism of injury for most elbow fractures is direct elbow trauma or a fall onto an outstretched hand. Patients may experience the following:

• Pain
• Swelling
• Decreased range of motion

Physical

• A thorough neurovascular examination is vital in the assessment of elbow fractures because of the high incidence of neurovascular injuries with elbow fractures and the subsequent long-term complications with these injuries.
• With supracondylar fractures, the incidence of anterior interosseous nerve injury is high, and specific muscle testing of flexion at the distal interphalangeal joint of the index finger should be performed.⁹
• Patients often have decreased range of motion, and pain is present with pronation/supination of the forearm.
• Edema and ecchymosis near the elbow may be evident.
• Perform careful shoulder and wrist examinations with all elbow injuries.

DIFFERENTIALS

Section 4 of 12  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

WORKUP

Section 5 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Imaging Studies

Anteroposterior (AP), lateral, and oblique radiographs of the elbow adequately visualize most elbow fractures.

To detect subtle elbow fractures, it is key to systematically view elbow films looking at certain aspects of the elbow.

• Anterior humeral line
• • This is a line that is drawn along the anterior aspect of the humeral shaft on the lateral radiograph.
  • The line passes through the middle one third of the capitellum in bones that are not injured.
  • Only true lateral views should be used to assess this line.
  • For example, a supracondylar fracture changes the anterior humeral line as it passes through the capitellum.
• Radiocapitellar line: This is a line that bisects the proximal radial shaft and should pass through the capitellum on every view.
• Fat pads (see Media file 8)
• • On lateral films, the anterior fat pad normally lies against the anterior surface of the distal humerus.
  • A joint effusion displaces this fat pad anteriorly and produces the sail sign.
  • The posterior fat pad is not visible in films of the normal elbow; in patients with suspected elbow fracture, a posterior fat pad should be treated as a fracture.
  • Fat pads may be elevated if fluid is present from other conditions such as joint infection or inflammation.
• Ossification centers
• • Often, the pediatric elbow is difficult to evaluate due to the ossification centers of the elbow.
  • One common mnemonic for the order of appearance for the ossification centers of the elbow is CRITOE:

Procedures

• In general, an orthopedic consultant best handles decisions regarding reduction of significantly angulated and displaced fractures.
• If neurovascular structures are compromised, the emergency physician may need to apply forearm traction to reestablish distal pulses.
• If pulse is not restored with traction, emergent operative intervention for brachial artery exploration or fasciotomy is indicated.

TREATMENT

Section 6 of 12  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Emergency Department Care

• Emergency physicians need to do a thorough neurovascular examination as well as evaluate for concurrent injuries.
• Provide adequate analgesia to achieve patient comfort in the ED.
• Proper immobilization for the various types of elbow fractures is indicated.
• Assess whether the patient needs orthopedic evaluation in the ED, admission to the hospital for observation, or if discharge and follow up with an orthopedic surgeon is adequate.

Consultations

• All elbow fractures should be referred for orthopedic follow-up.
• Urgent orthopedic consultation in the ED is required in the following situations:
• • If  an open fracture or an open joint is suspected 
  • If the injury poses a significant risk of neurovascular injury such as a displaced supracondylar fracture

MEDICATION

Section 7 of 12  

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• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Drugs used to treat fractures are generally NSAIDs, analgesics, and anxiolytics. In addition, administer proper antibiotics and tetanus prophylaxis for open fractures.

Drug Category: Nonsteroidal anti-inflammatory agents (NSAIDs)

These drugs are used commonly for relief of mild to moderately severe pain. Effects of NSAIDs in treatment of pain tend to be patient specific, yet ibuprofen is usually DOC for initial therapy. Other options include flurbiprofen, ketoprofen, and naproxen.

Drug Category: Analgesics

Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients with fractures.

Drug Category: Anxiolytics

Patients with painful injuries usually experience significant anxiety. Anxiolytics allow a smaller analgesic dose to achieve the same effect.

Drug Category: Antibiotics

These agents are given as prophylaxis to patients with open fractures.

Drug Category: Toxoid

This agent is used for tetanus immunization. Booster injection in previously immunized individuals is recommended to prevent this potentially lethal syndrome.

Drug Category: Immunoglobulins

Patients who may not have been immunized against Clostridium tetani products should receive tetanus immune globulin.

FOLLOW-UP

Section 8 of 12  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Further Inpatient Care

• Open fractures require extensive irrigation and appropriate prophylactic antibiotics, such as cefazolin and gentamicin.
• Displaced supracondylar fractures require surgical intervention and continual monitoring of neurovascular status.

Further Outpatient Care

• Supracondylar fracture
• • Refer patients with nondisplaced fractures to an orthopedist within 24 hours to evaluate and recheck neurovascular status.
  • Upon dissipation of edema, apply a long-arm cast that holds the elbow in 90° of flexion for approximately 6 weeks.
• Radial head fracture
• • For uncomplicated fractures, begin range of motion exercises within 3-7 days to reduce the risk of permanent loss of motion from elbow joint contracture.
  • Intra-articular fractures, which may require radial head excision or fixation, should be seen by an orthopedist within 1 week for definitive management.
• Olecranon fracture: Nonoperative fractures (minimally displaced with an intact extensor mechanism) can be treated with a splint and range of motion exercises within a few weeks.

In/Out Patient Meds

• As with all fractures, address adequate outpatient analgesia, especially during the first few days.
• Acetaminophen, with codeine or hydrocodone, may be appropriate treatment.

Complications

• Supracondylar fracture
• • Cubitus varus: The most common complication for supracondylar fractures are cubitus varus or “gunstock deformity,” which is a loss of the carrying angle and results in more of a cosmetic disability rather than a functional disability (see Media file 8).
  • Volkmann ischemia: This is a form of compartment syndrome that can lead to muscle ischemia and permanent muscle contracture, particularly occurring in children. Symptoms suggestive of this complication include pain with passive extension of the fingers, refusal to open the hand, and forearm tenderness.
  • Median nerve injury: Displaced supracondylar humerus fractures may lead to median nerve dysfunction. Rarely does this result in complete nerve transection, and full return of function is common.
  • Malunion: Angulated or displaced fractures that remain unreduced lead to functional and cosmetic deformities.
• Radial head fracture
• • Nondisplaced fractures that are immobilized for prolonged periods of time may have permanently decreased range of motion.
  • Comminuted radial head fractures associated with undiagnosed distal radial-ulnar joint injuries can lead to permanent wrist injuries and loss of pronation/supination motion.
• Olecranon fracture: An ulnar nerve injury, although rare, may be associated with a displaced olecranon fracture.

Prognosis

• Supracondylar fracture
• • Children: Undisplaced fractures and properly managed displaced/angulated fractures result in no long-term functional deficits.
  • Adults: Usually, range of motion decreases somewhat but without functional deficit.
• Radial head fracture: Usually, no functional loss occurs with nonoperative treatment.
• Olecranon fracture
• • This fracture may result in loss of full extension but usually restores strength.
  • Olecranon fracture can be associated with posttraumatic arthritis of the elbow.
  • Most operative and nonoperative cases of olecranon fracture have a good outcome with no long-term deficits.

Patient Education

• For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education articles, Broken Elbow and Elbow Dislocation.
• For more information, see Medscape’s Fracture Resource Center.

MISCELLANEOUS

Section 9 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Medical/Legal Pitfalls

• Failure to document a neurovascular examination in a child with a supracondylar fracture
• Failure to reexamine and document neurovascular examination following application of a splint, elbow flexion greater than 90° may obliterate pulse or compromise neurologic function
• Failure to pad the olecranon when splinting an olecranon fracture may lead to skin breakdown and iatrogenic open fracture
• Failure to maintain prolonged immobilization of radial head fractures leads to permanently decreased range of motion
• Failure to recognize a radial head dislocation associated with a fracture of the proximal ulna (Monteggia fracture or dislocation)

ACKNOWLEDGMENTS

Section 10 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Thank you Sabrina Sakata for your editing and encouragement.

MULTIMEDIA

Section 11 of 12  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Media file 1:  Intercondylar fracture.
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Media file 2:  Supracondylar fracture.
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Media file 3:  Displaced supracondylar fracture.
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Media file 4:  Medial epicondyle fracture.
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Media file 5:  Lateral condyle fracture.
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Media file 6:  Radial head fracture.
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Media file 7:  Olecranon fracture.
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Media file 8:  Anterior and posterior fat pads with radial head fracture.
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Media file 9:  Cubitus varus.
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Media type:  Illustration

REFERENCES

Section 12 of 12

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

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4. Brown IC, Zinar DM. Traumatic and iatrogenic neurological complications after supracondylar humerus fractures in children. J Pediatr Orthop. Jul-Aug 1995;15(4):440-3. [Medline].
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6. Harris IE. Supracondylar fractures of the humerus in children. Orthopedics. Jul 1992;15(7):811-7. [Medline].
7. Nicholson DA, Driscoll PA. ABC of emergency radiology. The elbow. BMJ. Oct 23 1993;307(6911):1058-62. [Medline].
8. Skaggs D, Pershad J. Pediatric elbow trauma. Pediatr Emerg Care. Dec 1997;13(6):425-34. [Medline].
9. Shearman C, el-Khoury GY. Pitfalls in the radiologic evaluation of extremity trauma: Part 1. The upper extremity. Am Fam Physician. 1998;58:1298. [Medline].
10. Karlsson MK, Hasserius R, Karlsson C, et al. Fractures of the olecranon: a 15- to 25-year followup of 73 patients. Clin Orthop. Oct 2002;205-12. [Medline].
11. Steinberg G, Adkins C, Baran D. Orthopaedics in Primary Care. 2^nd ed. Williams & Wilkins; 1992:62-85.
12. Roust AF, Bredenkamp JH, Uehara DT. Injuries to the elbow and Forearm. In: Tintinalli JE, Kelen GD, Stapczynski JS. Emergency Medicine: A comprehensive study guide ; 2003: 1691-1694. 6^th ed. New York: McGraw Hill Text; 2003:1691-1694.
13. Steinberg G, Adkins C, Baran D. Orthopaedics in Primary Care. 2^nd ed. Williams & Wilkins: 1992:62-85.

Article Last Updated: Jul 10, 2008