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Elbow Fracture Workup

  • Author: Daniel K Nishijima, MD, MAS; Chief Editor: Trevor John Mills, MD, MPH  more...
 
Updated: Jan 22, 2016
 

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.

In a study of plain radiographs in 3 emergency departments for acute, nonpenetrating elbow injuries in patients 5 years or older, the active 4-way range-range-of-motion test (full extension, flexion to 90°, full pronation, and supination) was found to be 99% sensitive for all injuries and 100% sensitive for all elbow injuries that required surgery.[11]

In a study of ultrasonography performed by pediatric emergency physicians for elbow fractures, a positive ultrasound result had a 98% sensitivity and a 70% specificity. A positive result was defined as an elevated posterior fat pad or lipohemarthrosis of the posterior fat pad.[12]

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

On lateral films, the anterior fat pad normally lies against the anterior surface of the distal humerus. See the image below.

Anterior and posterior fat pads with radial head f Anterior and posterior fat pads with radial head fracture.

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.[13]

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.

Table. CRITOE. (Open Table in a new window)

Ossification Centers Age of Appearance, y
Capitellum 1-2
Radial head 4-5
Internal (medial) epicondyle 4-5
Trochlea 8-10
Olecranon 8-9
External (lateral) epicondyle 10-11
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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.

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Contributor Information and Disclosures
Author

Daniel K Nishijima, MD, MAS Assistant Professor of Emergency Medicine, Associate Research Director, Department of Emergency Medicine, University of California, Davis, School of Medicine

Daniel K Nishijima, MD, MAS is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Matthew Goldman, MD Associate Medical Director, Department of Emergency Medicine, Southside Hospital, NS-LIJ

Matthew Goldman, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine

Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Additional Contributors

Francis Counselman, MD, FACEP Chair, Professor, Department of Emergency Medicine, Eastern Virginia Medical School

Francis Counselman, MD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Norfolk Academy of Medicine, Association of Academic Chairs of Emergency Medicine, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Tom Scaletta, MD President, Smart-ER (http://smart-er.net); Chair, 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

Disclosure: Nothing to disclose.

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

  2. Roust AF, Bredenkamp JH, Uehara DT. Injuries to the elbow and forearm. Tintinalli JE, Kelen GD, Stapczynski JS, eds. Emergency Medicine: A Comprehensive Study Guide. 6th ed. New York: McGraw Hill Text; 2003. 1691-1694.

  3. Goldflam K. Evaluation and treatment of the elbow and forearm injuries in the emergency department. Emerg Med Clin North Am. 2015 May. 33 (2):409-21. [Medline].

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

  5. 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.

  6. Brown IC, Zinar DM. Traumatic and iatrogenic neurological complications after supracondylar humerus fractures in children. J Pediatr Orthop. 1995 Jul-Aug. 15(4):440-3. [Medline].

  7. Harris IE. Supracondylar fractures of the humerus in children. Orthopedics. 1992 Jul. 15(7):811-7. [Medline].

  8. Nicholson DA, Driscoll PA. ABC of emergency radiology. The elbow. BMJ. 1993 Oct 23. 307(6911):1058-62. [Medline].

  9. Skaggs D, Pershad J. Pediatric elbow trauma. Pediatr Emerg Care. 1997 Dec. 13(6):425-34. [Medline].

  10. 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].

  11. Vinson DR, Kann GS, Gaona SD, Panacek EA. Performance of the 4-way range of motion test for radiographic injuries after blunt elbow trauma. Am J Emerg Med. 2015 Oct 24. [Medline].

  12. Rabiner JE, Khine H, Avner JR, Friedman LM, Tsung JW. Accuracy of point-of-care ultrasonography for diagnosis of elbow fractures in children. Ann Emerg Med. 2013 Jan. 61 (1):9-17. [Medline].

  13. Rabiner JE, Khine H, Avner JR, Tsung JW. Ultrasound findings of the elbow posterior fat pad in children with radial head subluxation. Pediatr Emerg Care. 2015 May. 31 (5):327-30. [Medline].

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

  15. Karlsson MK, Hasserius R, Karlsson C, et al. Fractures of the olecranon: a 15- to 25-year followup of 73 patients. Clin Orthop. 2002 Oct. 205-12. [Medline].

  16. Steinberg G, Adkins C, Baran D. Orthopaedics in Primary Care. 2nd ed. Williams & Wilkins; 1992. 62-85.

 
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Intercondylar fracture.
Supracondylar fracture.
Displaced supracondylar fracture.
Medial epicondyle fracture.
Lateral condyle fracture.
Radial head fracture.
Olecranon fracture.
Anterior and posterior fat pads with radial head fracture.
Cubitus varus.
Table. CRITOE.
Ossification Centers Age of Appearance, y
Capitellum 1-2
Radial head 4-5
Internal (medial) epicondyle 4-5
Trochlea 8-10
Olecranon 8-9
External (lateral) epicondyle 10-11
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