History

A thorough patient history must be taken in the initial evaluation of these patients. Medical history, surgical history (especially pertaining to the injured extremity), medication use, nonmedication drug use, occupation, and smoking history should be ascertained. In an elderly patient, the reason for the fall must be investigated.

The mechanism of injury also can help to identify other associated bony or ligamentous injuries. Questions regarding the speed of the motor vehicle accident (MVA) or the height from which a fall occurred and the position of the arm at impact should be asked.

Understanding the premorbid condition of the patient's injured extremity also is important, as is ascertaining any preexisting limitations, such as degenerative or traumatic arthritis, instability, stiffness, or neurologic abnormalities (acute or chronic), that may affect treatment.

With high-energy injuries, associated injuries to the head, chest, abdomen, spine, or pelvis must be excluded. Standard screening radiographs, including radiographs of the pelvis, spine, and chest, are obtained (see Workup).

Physical Examination

Physical examination of the patient should include examination of the injured extremity and a thorough primary and secondary survey to determine if any associated injuries are present.

A complete examination of the neurovascular status of the extremity should be conducted. An accurate assessment should be made of the sensory and motor contributions of the median (including the anterior interosseous), ulnar, and radial (including the posterior interosseous) nerves, as well as the medial and lateral antebrachial cutaneous nerves. The brachial artery and median nerves lie anterior to the elbow joint and are at risk for disruption.

The distal pulses should be palpated and the capillary refills should be assessed, with comparisons made to the contralateral upper extremity. If questions regarding vascular status arise, duplex Doppler studies or angiography should be performed (see Workup).

Inspection and palpation also should be part of the examination. Open wounds communicating with the joint are common with high-energy injuries. These wounds should initially be treated with antibiotics and tetanus prophylaxis. A povidone-iodine dressing should be placed over the wound to prevent further wound colonization and exposure.

The skin should be examined for bruising, ecchymosis, or lacerations, with these findings taken into consideration, especially if operative intervention is to be initiated. Bruising, ecchymosis, or lacerations may represent significant ligamentous damage and resultant instability.

A well-padded, well-molded splint with the elbow in slight flexion and neutral rotation provides stability and pain relief until definitive treatment is possible. The splint should be applied with a nonconstrictive dressing. Signs of compartment syndrome of the forearm or upper arm also should be clinically investigated.

Workup

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Media Gallery

Radiograph of a supracondylar-intracondylar distal humerus fracture. Note the posteromedial and posterolateral column plate placement used for reconstruction with the chevron osteotomy.
Lateral radiograph of a supracondylar-intracondylar distal humerus fracture. Note the distal extent of the contoured plate placed extra-articularly.
Radiograph of a supracondylar-intracondylar humerus fracture. Note the ipsilateral radial head fracture fixed through a posterior incision.
Lateral radiograph of a supracondylar-intracondylar distal humerus fracture with an ipsilateral radial head fracture.
Anteroposterior radiograph of a pediatric type III supracondylar humerus fracture. Note the lateral pinning.
Lateral and medial pinning of a type III extension-type supracondylar humerus fracture.
Lateral radiograph after open reduction and pinning of a type III supracondylar humerus fracture.
Lateral radiograph of a distal humerus fracture of the left elbow. Only the intra-articular portion of the lateral condyle is involved.
Anteroposterior radiograph following a distal humerus fracture of the right elbow.

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Author

Edward Yian, MD Consulting Staff, Department of Orthopedic Surgery, Southern California Permanente Group Orange County

Edward Yian, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

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.

Thomas R Hunt III, MD Professor and Chairman, Joseph Barnhart Department of Orthopedic Surgery, Baylor College of Medicine

Thomas R Hunt III, MD is a member of the following medical societies: American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, Southern Orthopaedic Association, AO Foundation, American Academy of Orthopaedic Surgeons, American Association for Hand Surgery, American Society for Surgery of the Hand, Mid-America Orthopaedic Association

Disclosure: Received royalty from Tornier for independent contractor; Received ownership interest from Tornier for none; Received royalty from Lippincott for independent contractor.

Chief Editor

Murali Poduval, MBBS, MS, DNB Orthopaedic Surgeon, Senior Consultant, and Subject Matter Expert, Tata Consultancy Services, Mumbai, India

Murali Poduval, MBBS, MS, DNB is a member of the following medical societies: Association of Medical Consultants of Mumbai, Bombay Orthopedic Society, Indian Orthopedic Association, Indian Society of Hip and Knee Surgeons

Disclosure: Nothing to disclose.

Additional Contributors

Peter M Murray, MD Professor and Chair, Department of Orthopedic Surgery, Mayo Clinic College of Medicine; Director of Education, Mayo Foundation for Medical Education and Research, Jacksonville; Consultant, Department of Orthopedic Surgery, Mayo Clinic, Jacksonville; Consulting Staff, Nemours Children's Clinic and Wolfson's Children's Hospital

Peter M Murray, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Reconstructive Microsurgery, Orthopaedic Research Society, Society of Military Orthopaedic Surgeons, American Association for Hand Surgery, American Society for Surgery of the Hand, Florida Medical Association

Disclosure: Nothing to disclose.