eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Fracture, Elbow: Follow-up

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

Follow-up

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.

Inpatient & Outpatient Medications

• 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 9).

• 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

Medicolegal 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)

Thank you Sabrina Sakata for your editing and encouragement.

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