eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Fracture, Elbow: Differential Diagnoses & Workup

Author: Daniel K Nishijima, MD, Staff Physician, Department of Emergency Medicine, University of California Davis Medical Center
Coauthor(s): Matthew Goldman, MD, Clinical Assistant Professor, Assistant Medical Director, Department of Emergency Medicine, Kings County Hospital Center; Clinical Assistant Professor, Department of Emergency Medicine, Downstate Medical Center
Contributor Information and Disclosures

Updated: Mar 27, 2009

Differential Diagnoses

Dislocations, Elbow
Fractures, Forearm
Fractures, Humerus
Pediatrics, Nursemaid Elbow

Workup

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)
Anterior and posterior fat pads with radial head ...

Anterior and posterior fat pads with radial head fracture.

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Anterior and posterior fat pads with radial head ...

Anterior and posterior fat pads with radial head fracture.


    • 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:

Open table in new window

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Table
Ossification CentersAge of Appearance, y
Capitellum1-2
Radial head4-5
Internal (medial) epicondyle4-5
Trochlea8-10
Olecranon8-9
External (lateral) epicondyle10-11
Ossification CentersAge of Appearance, y
Capitellum1-2
Radial head4-5
Internal (medial) epicondyle4-5
Trochlea8-10
Olecranon8-9
External (lateral) epicondyle10-11

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.

More on Fracture, Elbow

Overview: Fracture, Elbow
Differential Diagnoses & Workup: Fracture, Elbow
Treatment & Medication: Fracture, Elbow
Follow-up: Fracture, Elbow
Multimedia: Fracture, Elbow
References
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References

  1. Kuntz DG Jr, Baratz ME. Fractures of the elbow. Orthop Clin North Am. Jan 1999;30(1):37-61. [Medline].

  2. Gupta R. Intercondylar fractures of the distal humerus in adults. Injury. Oct 1996;27(8):569-72. [Medline].

  3. Wilkins KE. Fractures and dislocations of the elbow region. In: Rockwood CA, Wilkins KE, King RE, ed. Fractures in Children. 4th ed. Philadelphia: JB Lippincott; 1996:653.

  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].

  5. Geiderman JM. Humerus and elbow. In: Marx JA. Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice. 6th ed. Philadelphia: Mosby; 2006:Chap 49.

  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. 2nd 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, eds. Emergency Medicine: A Comprehensive Study Guide. 6th ed. New York: McGraw Hill Text; 2003:1691-1694.

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Further Reading

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Keywords

elbow fracture, broken bone, broken arm, broken elbow, elbow pain, fracture treatment, fracture symptoms, elbow dislocation, radial head fracture, olecranon fracture, supracondylar fracture, intercondylar fracture, epicondyle fracture, medial epicondyle fracture, lateral epicondyle fracture, condyle fracture, medial condyle fracture, lateral condyle fracture, trochlea fracture, capitellum fracture

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Contributor Information and Disclosures

Author

Daniel K Nishijima, MD, Staff Physician, Department of Emergency Medicine, University of California Davis Medical Center
Daniel K Nishijima, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Matthew Goldman, MD, Clinical Assistant Professor, Assistant Medical Director, Department of Emergency Medicine, Kings County Hospital Center; Clinical Assistant Professor, Department of Emergency Medicine, Downstate Medical Center
Matthew Goldman, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Francis Counselman, MD, Program Director, Chair, Professor, Department of Emergency Medicine, Eastern Virginia Medical School
Francis Counselman, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Norfolk Academy of Medicine, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Tom Scaletta, MD, President, Emergency Excellence (EmEx) (www.emergencyexcellence.com); Assistant Professor of Emergency Medicine, Rush Medical College, Cook County Hospital; Chairperson, Department of Emergency Medicine, Edward Hospital; Past-President, American Academy of Emergency Medicine
Tom Scaletta, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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