Lesson

Fractures

Elbow fractures may result from a fall, a direct impact to the elbow, or a twisting injury to the arm. They are especially common in paediatric football players. There are several characteristic fracture patterns. As with other body parts, the key to treating these injuries is early identification of the injury, ensuring that the fracture is reduced, and providing protection while the injury heals.

The most common complication with elbow fractures is stiffness, so an early focus on ROM exercises is suggested. The second most common complication is heterotrophic ossification, the risk of which may be reduced by avoiding the use of overly aggressive passive ROM immediately following injury.

 

History

Athletes generally present after an acute injury. The specific mechanism associated with each fracture type are considered below. In general, a fall onto an outstretched arm is the most common mechanism of injury in football.

 

Examination

Localised tenderness and significant swelling are all characteristic findings. When there is significant displacement an assessment of neurovascular status is needed.

 

Investigations

Fractures are generally readily seen on plain films. Where there is uncertainty, an athlete may be treated for a period of seven to ten days and have a repeat x-ray. Alternatively, CT imaging or MRI can be used to document the injury.

 

Treatment

In general terms, these fractures need prompt reduction and a period of immobilisation. When the fracture is unstable, or involves the joint surface, early surgical referral (and management) is advised. Any signifant deformity requires prompt reduction. This should not be delayed. Any change in neurovascular status requires immediate surgical management.

Click on the boxes below to learn more about the different fractures seen about the elbow.

Radial head fracture
These injuries typically occur following a fall onto an outstretched hand (FOOSH). If there is pain and tenderness at the radial head (lateral elbow), especially with pronation/supination motions, this injury should be suspected. Undisplaced fractures can be hard to visualise on radiographs.

The wrist, the interosseous space, and the medial side of the elbow should be examined for signs of associated ligament injury since up to one third of patients have associated injuries.12 It is also important to assess the range of forearm supination and pronation. If there is a displaced injury and a marked loss of movement, injecting the radio-capitellar joint with local anaesthetic can help determine if blocked motion is due to a displaced fragment or secondary to pain.

Most isolated fractures of the radial head can be treated non-operatively with a sling and early range of motion beginning 24 to 72 hours after injury as the pain subsides. Early mobilisation is very important. The main indications for surgery are displaced fractures with a block to motion or the presence of associated injuries that can result in an unstable elbow (soft tissue injuries, other fractures, or both).

Radial neck fracture
These involve a similar mechanism to radial head fractures and are managed in a similar way. Minimally or partially displaced injuries (type 1 and type 2) can generally be managed symptomatically with immobilisation. Grossly displaced fractures (type 3) may require open reduction and internal fixation.
Olecranon fracture
Olecranon fractures are usually the result of two types of mechanisms. Direct trauma to the olecranon typically results in a comminuted pattern while the more common sudden eccentric contraction of the triceps upon a flexed elbow leads to an oblique or transverse pattern of injury.

Non-displaced fractures can be treated in a long arm cast or splint with the elbow fixed at 45o to 90o of flexion. At three weeks, the cast can be removed from the patient with a stable fracture and protected range-of-motion exercises can begin; avoid active extension and flexion past 90 degrees. Displaced fractures are treated with open reduction and internal fixation. The main goal is a stable anatomical reduction that allows early range of motion.

Distal humerus fracture
Distal humerus fractures are relatively uncommon, compromising only 2% of all adult elbow fractures.13 In these cases, a careful neurovascular evaluation is particularly important because fracture fragments may cause injury to the brachial artery as well as to the median nerve and the radial nerve. CT can be especially helpful to delineate fracture fragments.

Many different types of fractures (including extra-articular, intra-articular and avulsion patterns) can occur to the distal humerus. Each type of fracture has its particularities, but general treatment principles suggest that one must consider the need to achieve anatomic articular reduction, restoration of the carrying angle (4o to 8o) and obtaining stable internal fixation that allows an early range of motion.

Supracondylar fracture
These fractures are generally unstable and require referral to an orthopaedic surgeon. These are most common in children and adolescents. There is a high rate of neurovascular compromise and as a result these fractures need early reduction and internal fixation (generally with k-wires) when displaced. The other main complication is a rotational deformity as this affects the carrying angle. There are three grades of injury:
  • Grade 1: Undisplaced (generally no operative intervention required)
  • Grade 2: Displaced, posterior cortex intact
  • Grade 3: 100% displacement

Grade 2 and 3 injuries typically require reduction and temporary fixation with k-wires.

Click on the following images to observe examples of fractures about the elbow.

  • Distal humerus fracture

    AP and lateral views of a fracture involving the distal humerus.

  • Radial neck fracture

    Note the relatively undisplaced radial neck fracture.

  • Olecranon fracture

    An olecranon fracture.

  • Olecranon fracture – fixed

    Olecranon fractures almost always require surgical fixation.