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Elbow Fracture

Fracture of Elbow

Elbow fractures occur when an injury leads a to loss of the bone integrity around the hinge joint formed by the radius, ulnar and humerus.


Presentation

A number of signs and symptoms point towards a diagnosis of an elbow fracture following an injury to the elbow itself or to any other part of the arm or forearm. Some of the characteristic clinical features include:

  • Impaired range of movement of the elbow joint
  • Pain and difficulty in moving the elbow joint
  • Bony deformity at or around the elbow
  • Edema around the site of injury
  • Presence of obvious injury such as bruising or redness around the elbow
  • Sensation of tightness in the forearm
  • Loss of sensation in the upper limb due to injury of the radial, median or ulnar nerve [8]

Examining the range of joint movement can help to determine the type of elbow fracture. A diagnosis of radial head fracture is highly likely to be made when a patient exhibits a loss of ability to rotate the elbow internally and externally. On the other hand, failure of the patient to flex and extend the elbow points towards a supracondylar fracture.

Collapse
  • There were six complications in six patients, including three contractures with associated heterotopic ossification, one pronator syndrome and late radial nerve palsy, one radial head collapse, and one with prominent hardware.[ncbi.nlm.nih.gov]
  • The more severely broken fragment (measured by the humeral-capitellar angle), and the degree of medial sided bone collapse (called Baumanns angle) are risk factors for re-separation and encourage pin fixation.[bonetalks.com]
Elbow Swelling
  • Additional visual symptoms such as a lump or deformity of the elbow, swelling and discoloration from bruising or redness may be present.[handtoshoulderwisconsin.com]
  • Furthermore, symptoms of an elbow fracture can include: Feelings of instability, as if the elbow is going to “pop out” Sudden and strong pain, often worse with movement Inability to straighten the elbow Swelling or bruising Tenderness at the joint Numbness[oshmanlaw.com]
  • Signs and symptoms Impaired range of movement of the elbow joint Pain and difficulty in moving the elbow joint Deformation of the bones around the elbow Swelling around the joint Bruising and redness on the skin around the joint Sensation of tightness[symptoma.com]
Confusion
  • Whether eponyms should continue to be used is a question that remains unanswered, but if we use them, knowledge of the original description can prevent confusion and knowledge of the historical background sheds light on the interesting roots of our profession[ncbi.nlm.nih.gov]
  • They include among others: [1] Olecranon fractures Supracondylar humerus fractures Radial head fractures The terrible triad of the elbow (not to be confused with the terrible triad of the knee) is a combination of: [2] A fracture of the head of radius[en.wikipedia.org]
  • This injury is often confused with medial epicondyle fractures.[emedicine.medscape.com]
  • Medial Epicondyle Avulsion • Avulsed medial epicondyle becoming entrapped in the dislocated joint • Don’t confuse with Trochlea ossification centers 37.[slideshare.net]

Workup

The main investigative procedure recommended for elbow fractures is radiography. Diagnosis is made by identifying the fracture in lateral and anterior-posterior radiographs. Radiographs of the normal limb are also taken to compare with the fractured limb. This is particularly important in children because in this age group the presence of growth plates can be mistaken for fractures. Other imaging tests that can be carried out include computed tomography (CT) scanning of the elbow joint [9] or alternatively an elbow joint magnetic resonance imaging (MRI) [10].

Concerns of injury to a blood vessel may provide indication for an arteriogram.

Laboratory blood tests are not indicated unless as part of pre-operative preparation of the patient.

Staphylococcus Aureus
  • Staphylococcus aureus was the most common bacteria cultured (59%). CONCLUSIONS: The only modifiable risk factor for a surgical site infection after open reduction and internal fixation was cigarette smoking.[ncbi.nlm.nih.gov]

Treatment

For treatment of elbow fractures, consultation with an orthopedic surgeon is necessary. The goals of treatment and the possible approaches include the following:

  • Immobilization via splinting or use of arm slings for un-displaced fractures.
  • Proper alignment of the fractured segments in displaced fractures. This demands for surgery where open reduction and internal fixation is carried out to repair the fracture.
  • Pain relief by use of analgesics.

Prognosis

Generally, elbow fractures in children heal much better than in adults. However, in both groups the process may be inhibited by a number of complications which can potentially arise as a result of the fracture itself or from the surgical intervention that may be carried out. These complications impact negatively on the prognosis, the common ones being the following:

  • Increased risk of bone infection due to direct exposure to the skin in compound fractures [7].
  • Injury to adjacent blood vessels especially when the fracture impinges on a large blood vessel.
  • Median, radial or ulnar nerve injury due to direct trauma or the limb edema that occurs following injury [8].
  • Non-union, where there is failure of the distal and proximal fracture segments in uniting to facilitate healing.
  • Mal-union where there is abnormal reduction of the fractured segments.
  • Joint stiffness with reduced range of motion (more common in adults).
  • Arthritis secondary to the trauma itself which triggers inflammation.
  • Implant related complications (infection, mal-position, pain) following surgical interventions with fixation of implants to reduce the fracture.

Etiology

Elbow injuries highly occur in the set-up of acute trauma which may include [2]:

  • Direct blow on or around the elbow joint
  • Falling on an outstretched arm or open hand such as by slipping backwards
  • High energy impact commonly due to motor vehicle or motorbike accidents
  • Transmission of energy to the elbow from a direct injury on the shoulder, the wrist or the hand
  • Injury from the side on a flexed elbow such as one protruding outwards from the window of a vehicle.

Sometimes though, elbow fractures develop as a result of limb overuse particularly during sports.

Epidemiology

Radial head fractures are the most common elbow fracture in adults.

Owing to the nature of the anatomy around the elbow joint in different age groups, fracture patterns will vary. Among the adults, the most common fracture pattern seen is that involving the radial head while in children supracondylar fractures predominate with an incidence rate of 308 per 100,000 per annum [3].

Sex distribution
Age distribution

Pathophysiology

The most common causes of elbow injury include falling on the outstretched arm or open hand and experiencing a direct blow to the elbow. Apart from the elbow fracture that arises, injury to the neurovascular bundle may also ensue. In supracondylar fractures, the most common nerve injury involves the median nerve while the most common vessel injury affects the brachial artery. Below is a table illustrating the different fracture patterns that occur:

Fracture pattern Occurrence Unique complications Cause of fracture
Intercondylar fractures More common in adults than in children Separation of the condylar fragments.
Supracondylar fractures The most common fracture in children consisting of 60% of all fractures. Rare beyond the age of fifteen [4]. 95% of supracondylar fractures are the extension type and the remaining 5% are flexion type. Commonly causes injuries to the median nerve, radial nerve and anterior interosseous nerve. Extension type occurs due to an extension force that also causes posterior displacement while flexion type occurs from flexion force that causes anterior displacement.
Medial epicondyle fracture More common in children Due to avulsion injury following elbow dislocation posteriorly or out of the impact of a direct blow.
Lateral epicondyle fracture Uncommon in all age groups Due to avulsion injury. Its appearance on a radiograph may resemble the radiolucency of the epiphysis [5].
Medial condyle fracture Occurs in children, although rarely. Results from a fall on the outstretched hand or the shear impact from extreme valgus deformity.
Lateral condyle fracture The second most common fracture in the pediatric population [6]
Trochlea fracture Rarely occurs in isolation unless in combination with other elbow fractures
Capitellum fracture Occurs concurrently with posterior elbow dislocations or fractures of the radial head; rarely in isolation Results from a fall on the outstretched hand.
Radial head fractures The most common elbow fracture especially in adults Related injuries are very common. Due to a fall on an outstretched hand.
Olecranon fractures Due to fall on an outstretched hand or a direct blow force

Prevention

Prevention of elbow fractures lies in averting elbow injuries. Therefore, certain measures have to be put in place especially when engaging in sports activities. It is of utmost importance to protect the elbow by using well fitting pads during sports. Before engaging in intense activity the body ought to be prepared by taking on warm up exercises. It is beneficial as well to maintain body fitness through regular exercise.

Summary

The elbow joint is formed by three different bones: the humerus, radius and ulna which form the bony structure of the arm and the forearm. Other structures that comprise the elbow joint include muscles, tendons and ligaments. This joint functions to support flexion, extension and rotational movements.

Elbow fractures arise from injury to either one or more of the three bones that form this joint. The fractures are categorized as intra-articular or extra-articular depending on the site of injury. Intra-articular fractures consist of all fractures that involve the head of radius, proximal ulnar, trochlea and capitellum. On the other hand, extra-articular fractures are those that affect the condyles, epicondyles, supracondylar area and the intercondylar area [1].

Injuries that cause elbow fractures commonly occur in both children and adults thus demanding prompt recognition and management to prevent development of fracture related complications. This is especially important in children who still have active bone growth plates since it will help avert premature arrest of bone development.

Patient Information

An elbow fracture refers to a localized fragmentation of one or more of the bones that form the elbow joint. This joint is formed by three bones: one in the arm (humerus) and two in the forearm (radius and ulnar).

Causes

Elbow fractures almost always occur as a result of injury to the arm or the forearm and sometimes, injury to the hand. The mechanism of injury that leads to formation of the fracture is commonly a direct blow to the elbow or the force generated from falling on the outstretched arm. Instances when these can occur include slipping and falling backwards, being hit on a flexed elbow from the side or a high energy compression during a motor vehicle collision.

Signs and symptoms

  • Impaired range of movement of the elbow joint
  • Pain and difficulty in moving the elbow joint
  • Deformation of the bones around the elbow
  • Swelling around the joint
  • Bruising and redness on the skin around the joint
  • Sensation of tightness in the forearm
  • Numbness in the forearm or the hands

Diagnosis

X-rays of the injured limb are used to confirm the presence of an elbow fracture. Other possible imaging tests that can be carried out include a computed tomography (CT) scan or a magnetic resonance imaging (MRI).

Treatment

For simple fractures, immobilization of the joint may be sufficient to allow healing. This is done using splints or arm slings. For more severe fractures surgery may be required in order to re-align the bones and fix them in place using orthopedic implants. Pain relieving drugs are also prescribed.

References

Article

  1. Kuntz DG Jr, Baratz ME. Fractures of the elbow. Orthop Clin North Am. 1999 Jan; 30(1):37-61.
  2. Knapp K. The Elbow. In Hannon, Patrick; Knapp, Kerry. Forensic Biomechanics. Lawyers & Judges. 2006; pp. 243–8. ISBN 978-1-930056-27-5.
  3. Houshian S, Mehdi B, Larsen MS. The epidemiology of elbow fracture in children: analysis of 355 fractures, with special reference to supracondylar humerus fractures. J Orthop Sci. 2001; 6(4):312-5.
  4. Wilkins KE. Fractures and dislocations of the elbow region. Rockwood CA, Wilkins KE, King RE, ed. Fractures in Children. 4th ed. Philadelphia: JB Lippincott. 1996; 653.
  5. Nicholson DA, Driscoll PA. ABC of emergency radiology. The elbow. BMJ. 1993 Oct 23; 307(6911):1058-62.
  6. Skaggs D, Pershad J. Pediatric elbow trauma. Pediatr Emerg Care. 1997 Dec; 13(6):425-34.
  7. Murphy WA, Siegel MJ. Elbow fat pads with new signs and extended differential diagnosis. Radiology. 1977 Sep; 124(3):659-65
  8. Goldflam K. Evaluation and Treatment of the Elbow and Forearm Injuries in the Emergency Department. Emerg Med Clin North Am. 2015 May; 33(2):409-421.
  9. Sormaala MJ, Sormaala A, Mattila VM, et al. MDCT findings after elbow dislocation: a retrospective study of 140 patients. Skeletal Radiol. 2014 Apr; 43(4):507-12.
  10. Schreiber JJ, Potter HG, Warren RF, et al. Magnetic resonance imaging findings in acute elbow dislocation: insight into mechanism. J Hand Surg Am. 2014 Feb; 39(2):199-205.

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Last updated: 2018-06-22 10:18