Elbow fractures in adults and children are among the most complex of all fractures. The higher complication rate and need for near-anatomic reduction in these fractures necessitate orthopedic referral in most cases. Primary care providers play an important role in the prompt diagnosis of elbow fractures that need referral and in the treatment of nondisplaced fractures with splinting and early motion. Knowledge of normal elbow anatomy and radiographic alignment is essential in detecting displacement of fracture fragments, especially with intraarticular injuries. Encouragement of early motion to prevent joint stiffness is important in the successful management of any elbow fracture.
Elbow fractures represent approximately 10% of all fractures in children. The diagnosis and management of these injuries are complex, and most fractures should be managed by an orthopedist. The large amount of nonossified cartilage around the elbow makes detection of fractures difficult. Elbow fractures in children can lead to neurovascular injury, which further complicates management.
Go to Expert Consult for the electronic version of a patient instruction sheet named “Broken Elbow,” which covers the steps of care from pain relief to rehabilitation exercises. This can be copied to hand out to patients to assist them during the treatment period.
Radial Head and Neck
Radial head and neck fractures are common and account for approximately one third of all elbow fractures in adults. Most occur in middle adulthood (age 30 to 40 years). Other upper extremity injuries are frequently associated with radial head fractures.
The radial head is a thick, disk-shaped end of the proximal radius with a shallow concavity for articulation with the capitellum of the distal humerus ( Figure 7-1 ). The neck is the narrowed area just below the head, and the tuberosity is a medial prominence just distal to the neck. A fall on an outstretched hand directs a longitudinal force from the wrist to the elbow, resulting in compression of the radial head against the capitellum. The radial head also articulates medially with the lesser sigmoid (radial) notch of the ulna. The annular ligament arises from the lateral collateral ligament complex, encircles the radial head, and attaches to the radial notch. This strong ligament prevents displacement of the radial head from its articulation with the ulna.
The radial head moves with forearm rotation as well as flexion and extension. It can be palpated in the depression about 1 inch distal to the lateral epicondyle with the elbow flexed to 90 degrees. It is medial and posterior to the wrist extensor muscle group. As the patient pronates and supinates the forearm, the radial head can be felt to rotate under the examiner’s thumb ( Figure 7-2 ).
Mechanism of Injury
Fractures of the radial head and neck most commonly occur as a result of a fall on an outstretched hand. In general, the severity of the fracture is proportional to the force applied during the fall. A valgus compressive force or direct trauma to the elbow may also fracture the radial head. Radial head fractures may occur in association with other fractures, dislocations, or soft tissue injuries, and detection of these associated injuries is important for proper treatment.
The patient with a radial head or neck fracture has swelling over the lateral elbow and limited range of motion (ROM), especially in forearm rotation and elbow extension. Pain increases with passive rotation. Point tenderness over the radial head is the most reliable finding. A careful neurovascular examination with particular attention to radial nerve function (tested using the thumb’s up sign) is essential.
If the patient has significantly restricted elbow motion, it is most often attributable to joint distension and pain from a hemarthrosis, but occasionally a displaced fracture fragment causes a mechanical block to motion. Aspiration of the hemarthrosis and instillation of local anesthetic for pain relief are often necessary to perform a better evaluation of joint motion. The technique for joint aspiration is as follows:
Prepare the lateral elbow using sterile technique.
Visualize an imaginary triangle connecting the radial head, the lateral epicondyle, and the olecranon ( Figure 7-3 ).
Anesthetize the skin.
Insert an 18-gauge needle on a 20-mL syringe through the joint capsule at the center of the triangle. Aspirate as much blood as possible.
Change syringes and instill 3 to 5 mL of a half-and-half mixture of 1% bupivacaine and 1% lidocaine without epinephrine.
After the procedure, detecting severe crepitation or complete blockage of motion through full extension and flexion indicates the presence of displaced fragments.
If the patient has significant wrist pain, central forearm pain, or both, an acute longitudinal radioulnar dissociation with disruption of the distal radioulnar joint (the so-called Essex-Lopresti fracture) may have occurred.
Anteroposterior (AP) and lateral views of the elbow are usually sufficient to detect a radial head or neck fracture. A radiocapitellar view, an oblique view with the forearm in neutral rotation and the x-ray beam angled 45 degrees cephalad may be needed to visualize a fracture. These fractures can be quite subtle, with the only clue to their presence being a fat pad sign ( Figure 7-4 ). The fat pad sign occurs when the capsule around the elbow joint is distended by an intraarticular hemarthrosis. A small oval anterior fat pad may be a normal finding, but a sail-shaped lucency in front of the joint indicates a joint effusion ( Figure 7-5 ). A lucency behind the joint indicates a posterior fat pad and is always abnormal. A fracture of the radial neck does not necessarily give rise to a fat pad sign because it is extraarticular.
Fracture patterns seen include damage to the articular surface, depression of the head, and angulated fractures of the head or neck ( Figure 7-6 ). The radiographs should be examined closely to detect fragments lying free within the joint. These suggest chip fractures of the capitellum because radial head fracture fragments are rarely displaced proximally.
Radial head fractures are usually classified according to a modified Mason classification, which adds a fourth category to the original scheme to account for those fractures associated with an elbow dislocation. The classification is based on the amount of head involvement and the degree of displacement and two thirds of radial head fractures are Type I:
Type I: Fissure or marginal sector, nondisplaced
Type II: Marginal sector, displaced
Type III: Comminuted involving entire head
Type IV: Fracture with associated elbow dislocation
Computed tomography (CT) may be needed to fully assess fracture displacement or comminution when surgery is being considered.
Indications for Orthopedic Referral
Emergency orthopedic referral should be obtained for any patient with an open fracture, elbow fracture dislocation, or any evidence of neurovascular injury.
Patients with fractures that are displaced more than 2 mm, involve more than one third of the articular surface, are angulated more than 30 degrees, are depressed more than 3 mm, or are severely comminuted should be referred for consideration of operative management. The presence of any mechanical block regardless of the radiographic appearance of the fracture requires referral.
The criteria for open reduction of radial head and neck fractures vary. The factors that influence treatment choice include the amount of displacement; presence or absence of mechanical block; associated injuries such as radioulnar dissociation, elbow dislocation, or fracture of the coronoid; and the anticipated demand on the elbow. Excision of the radial head was formerly common in the management of radial head fractures, but this method of treatment has come under greater scrutiny, especially in younger, more active patients. The treatment of type II fractures remains controversial because both nonoperative and operative approaches can produce satisfactory results so decision-making is best left to an orthopedist. The majority of type III and IV fractures require surgery, which often entails radial head resection and prosthetic replacement.
Table 7-1 summarizes management guidelines for fractures of the radial head and neck.
|Splint type and position||Long-arm posterior splint|
|Elbow in 90 degrees of flexion|
|Consider aspiration of hemarthrosis|
|Initial follow-up visit||Within 1 week|
|Patient instruction||Icing and elevation in first 48 hours|
|Forearm rotation as soon as pain permits|
|follow – up care|
|Cast or splint type and position||Sling for comfort only|
|Length of immobilization||1 week|
|Healing time||8 to 10 weeks to restore motion|
|Follow-up visit interval||Every 2 weeks to assess return of normal elbow motion|
|Repeat radiography interval||At first visit to check position or look for signs of initially occult fracture|
|Patient instruction||Active ROM exercises (forearm rotation, flexion, and extension) at least|
|three to four times each day|
|Physical therapy referral if no or little progress|
|Some loss of extension expected|
|Indications for orthopedic consult||Fracture dislocation|
|Mechanical block to motion|
|>2 mm displacement|
|>One third of the articular surface involved|
|>3 mm depression|
|>30 degrees of angulation|
Dramatic pain relief can be provided by aspiration of blood from the elbow joint and instillation of a local anesthetic as described previously. Relieving the hemarthrosis may also allow the patient to begin moving the elbow sooner. Patients with nondisplaced fractures of the head or neck or those awaiting consultation with an orthopedist should have the arm immobilized in a long-arm posterior splint with the elbow at 90 degrees. They should be instructed to apply ice to the elbow and elevate it for the first 48 hours. The patient with a nondisplaced fracture should begin forearm rotation out of the splint as soon as pain permits, usually within the first few days. The patient should be seen in 1 week.
During the first follow-up visit, the posterior splint should be discontinued and the patient given a sling for comfort only. Repeat radiographs should be obtained to look for any further displacement of the fracture fragments or to look for evidence of a fracture if only a fat pad sign was visible initially.
Early motion is an important factor in a faster recovery. Active ROM exercises, including forearm rotation, flexion, and extension, should be performed at least three or four times per day. Achieving maximum degrees of motion is preferred over trying to increase the number of repetitions. The patient should be advised that pain and stiffness will be present for several weeks, but most patients can expect good to excellent function after 2 to 3 months of rehabilitation. Patients who fail to make gradual progress in gaining elbow motion should be considered for physical therapy referral. Some loss of extension (10 to 15 degrees) is common but generally does not affect function.
Return to Work or Sports
Early return to work and daily activities is advisable to maximize function. The patient can participate in activities as tolerated after the initial weeks of immobilization in the posterior splint and sling. Work and sports activities will be limited by relative weakness of the forearm muscles caused by the injury, and activities requiring strength should be modified accordingly. Contact and collision sports should be avoided until the individual has normal strength and close to normal ROM. It may take 1 to 2 months to achieve the last 15 to 20 degrees of elbow extension, and most individuals will have good function despite this lack of full extension. Additional protection or bracing is not necessary for returning to sports.
The majority of patients with a nondisplaced fracture of the radial head or neck have a good clinical outcome. Mild limitation of extension or forearm rotation is the most common complication. Painful arthritis is an uncommon result. Some radial head fractures have an associated osteochondral fracture of the capitellum that was not detected on initial radiographs. This associated injury often leads to an increased incidence of osteoarthritis and joint stiffness and pain. Radial head excision can be complicated by proximal migration of the radius, elbow instability, distal radial–ulnar joint pain, or decreased forearm strength.
Radial Head and Neck Fractures
Radial head and neck fractures represent a small percentage of all elbow fractures in children. The low rate of fracture probably results from the large amount of cartilage in the radial head in skeletally immature children. The usual cause is a fall on an outstretched hand with valgus force applied across the radiocapitellar joint. Fractures of the radial neck usually occur through the physis (Salter-Harris type I or II) or just distal to the physis. The radial head can be angulated (usually apex ulnar angulation) or translocated after these injuries ( Figures 7-7 and 7-8 ). Other injuries, such as elbow dislocation, fractures of the olecranon, or avulsion of the medial epicondylar apophysis, may be associated with radial head and neck fractures.
If the angulation of the radial head is less than 30 degrees and less than 4 mm of translocation is apparent, the fracture can be treated with a brief period of sling immobilization and early ROM exercises started 7 to 10 days after injury. Healing time is usually 3 to 4 weeks, and children generally need a shorter time to return to full elbow motion than adults. Displaced fractures should be immobilized in a posterior splint and the patient referred to an orthopedist for closed or open reduction. Residual tilt of the radial head is better tolerated than translocation of the head.
Radial Head Subluxation (Nursemaid’s Elbow)
Go to Expert Consult for a video on how to perform a reduction maneuver for a radial head subluxation. Radial head subluxation, also known as nursemaid’s elbow, is one of the most common elbow injuries in children, typically occurring between ages 1 and 4 years, with a peak incidence between 2 and 3 years of age. The usual cause of injury is sudden longitudinal traction on the arm with the elbow extended such as that occurs when a child is pulled up by the arm. This force causes the annular ligament, which tethers the radial head to the adjacent ulna, to slip proximally and become interposed between the radius and the capitellum. Before the age of 3 years, the radial head is smaller than the diameter of the annular ligament and more easily slips out from beneath it when longitudinal force is applied to the arm.
After a radial head subluxation, the child reports pain and stops using the affected arm. The arm is usually held with the elbow in a slightly flexed and pronated position or with the elbow fully flexed. Any attempt to move the arm is resisted, and pain is most often elicited with supination. Radiograph results are often normal and not helpful before reduction unless the history and examination are confusing or the mechanism of injury is other than a pull or twisting trauma. Radiographs should be obtained if reduction is unsuccessful.
Reduction of radial head subluxation does not require any analgesia or sedation and can be performed in the office. Supination/flexion and hyperpronation are the two techniques for reduction and both are effective. A systematic review found that reduction on the first attempt was more likely with hyperpronation though the evidence quality was low. The method most commonly used is the supination/flexion method. This is performed by supination of the forearm followed by one smooth motion of flexion and pronation of the elbow while pressure is applied over the radial head ( Figure 7-9 ). In the hyperpronation method, the examiner supports the child’s arm at the elbow with one hand, grips the child’s distal forearm with the other hand, and hyperpronates the forearm while pressure is applied over the radial head. A sudden release of resistance and the sensation of a pop signify reduction of the radial head. Usually within minutes, the child is comfortable and begins using the arm again. It may take up to 24 hours for the child to move the elbow normally. Immobilization is not necessary after this injury. If the child has not resumed normal activity after 24 hours, the parents should be advised to return to the office for a reevaluation of the injury, including radiographs. Prolonged symptoms and an irreducible subluxation indicate the need for orthopedic referral.
Recurrence of this injury is common, occurring in one quarter to one third of children, and should not be a cause for concern as long as the injury is reducible each time. Rarely does recurrent subluxation result in any permanent sequelae. To reduce the chance of reinjury, parents should be advised after the first episode to avoid lifting their child by the wrist. With time, as the radial head becomes larger and at less risk of subluxation, the child outgrows this condition, usually by age 4 or 5 years.
The olecranon process and coronoid process together form the trochlear notch, which articulates with the trochlea of the distal humerus and provides bony stability for flexion and extension of the elbow (see Figure 7-1, C ). The triceps muscle inserts by a broad tendinous expansion on the posterior aspect of the olecranon. The ulnar nerve lies in the groove between the olecranon process and the medial epicondyle and may be injured in association with a fracture of the olecranon ( Figure 7-10 ).
The olecranon process is nearly subcutaneous, with only the olecranon bursa and triceps aponeurosis covering it. This superficial position makes it more susceptible to direct trauma. Most fractures are intraarticular, and near-anatomic alignment is necessary to ensure full ROM of the elbow. The amount of fracture displacement present often depends on the integrity of the triceps attachment and the force of the pull of the triceps muscle.
Mechanism of Injury
Most fractures of the olecranon occur as a result of direct trauma to the point of the elbow during a fall or from an object striking the elbow. These fractures are usually comminuted. An indirect force from a fall on a partially flexed elbow may result in a transverse or oblique fracture caused by forceful contraction of the triceps muscle.
The patient has swelling and tenderness over the olecranon. Because most of the fractures are intraarticular, a hemarthrosis develops and limits ROM. The patient may be unable to actively extend the elbow against gravity if the triceps muscle is significantly injured. Documenting neurologic function of the arm and hand is essential because ulnar nerve injuries may accompany comminuted fractures of the olecranon.
A true lateral view of the elbow is best for delineating fractures of the olecranon. Fracture patterns observed include avulsion, transverse, oblique, and comminuted. The radiographs should be examined carefully for the amount of displacement, extent of articular surface involved, and degree of comminution ( Figure 7-11 ). Any fracture with less than 2 mm of displacement and no change in position with gentle flexion to 90 degrees and extension against gravity is considered nondisplaced and stable.
Indications for Orthopedic Referral
All displaced fractures of the olecranon require open reduction with internal fixation (ORIF), because closed reduction rarely achieves the near-anatomic alignment of the articular surface needed for a good functional result. If the patient is unable to actively extend the elbow, which indicates loss of triceps function, an orthopedic surgeon should be consulted.
Table 7-2 summarizes management guidelines for nondisplaced fractures of the olecranon.
|Splint type and position||Long-arm posterior splint|
|Elbow in 90 degrees of flexion|
|Collar and cuff or arm sling for support|
|Initial follow-up visit||Within 5 to 7 days|
|Patient instruction||Icing, elevation|
|follow – up care|
|Cast or splint type and position||Removable posterior splint or sling for comfort|
|Length of immobilization||2 to 3 weeks|
|Healing time||6 to 8 weeks for fracture union|
|8 to 10 weeks to restore motion|
|Follow-up visit interval||Every 2 weeks|
|Repeat radiography interval||At 1, 2, and 4 weeks|
|Check for any displacement|
|Patient instruction||Forearm rotation within 1 week of injury|
|Flexion and extension at 2 weeks|
|Some loss of extension is expected|
|Flexion >90 degrees to be avoided until radiographic healing is apparent|
|Indications for orthopedic consult||>2 mm displacement|
|Any change in fracture position with flexion and extension|
|Inability to actively extend the elbow against gravity|