Elbow Fracture 

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

Overview

Background

Elbow fractures are commonly encountered in the acute care setting. Injury patterns for children and adults are quite different. Fractures of the elbow include extra-articular and intra-articular fractures. Extra-articular fractures include intercondylar fractures, supracondylar fractures, epicondylar fractures, and condyle fractures. Intra-articular fractures include trochlea and capitellum fractures, radial head, proximal ulnar fractures. The examining physician must perform a thorough neurovascular examination with all suspected elbow fractures; recognize subtle fracture patterns; provide adequate immobilization; and assess whether fractures require admission, immediate orthopedic evaluation, or less urgent referral.[1, 2, 3]

Anatomy

The elbow is a hinge joint composed of 3 bones: the ulna, the radius, and the humerus. The 3 main articulations of the elbow are (1) the humeroradial articulation, which is formed by the radial head and the capitellum of the humerus; (2) the humeroulnar articulation, which is formed by the ulnar notch and the trochlea of the humerus; and (3) the superior radioulnar articulation, which is formed by the proximal part of the ulna and the radius. All articulations are contained in one synovial-lined capsule, which typically encases a hemarthrosis following injury.

Two main movements occur at the elbow: flexion and extension, which occurs primarily at the humeroulnar articulation, and pronation and supination, which occurs primarily at the radioulnar articulation.

Pathophysiology

Fracture patterns vary widely due to the mechanism of injury as well as the age of the patient. Direct trauma or a fall onto an outstretched hand is responsible for most elbow fractures. Neurovascular injury is a common complication of elbow fractures. The brachial artery is the most commonly injured artery and is seen especially in supracondylar fractures. The median nerve is the most commonly injured nerve, which is often is due to a displaced supracondylar humerus fracture.

Extra-articular Fracture Patterns

Intercondylar fractures

Intercondylar fractures occur when the condylar fragments are separated. See the image below.

Intercondylar fracture. Intercondylar fracture.

They are much more common in adults than in children. Any distal humerus fracture in adults is more likely intercondylar than supracondylar.

The mechanism is force directed against the posterior elbow such as a fall onto a flexed elbow, driving the olecranon against the humeral articular surface separating the condyles.

Fractures are often a T or Y shaped fracture of the distal humerus.

Treatment is often complicated and requires anatomic reduction either open or closed.[4]

Supracondylar fractures

The supracondylar fracture is the most common pediatric elbow fracture (60%) with the average age of 6.7 years and rarely seen after age 15 years.[5] See the image below.

Supracondylar fracture. Supracondylar fracture.

Complications include injuries to nerves (the median, radial, and anterior interosseous nerves are the most commonly injured).

Most deficits are neurapraxias that resolve with conservative management

Motor function usually recovering in 7-12 weeks while sensory function usually recovers in 6 months.[6]

Vascular injuries should always be suspected with supracondylar fractures.

Ten percent of children have temporary loss of the radial pulse due to swelling and not direct arterial injury.[1]

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 the image below).

Cubitus varus. Cubitus varus.

Although rare (< 0.5%), the most serious complication is Volkmann ischemic contracture due to post-fracture swelling, producing increased pressure in the forearm compartment leading to muscle and nerve necrosis and eventual replacement by fibrotic tissue producing contracture.[7]

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.

In children, nondisplaced, nonangulated fractures can be splinted (elbow in 90° of flexion); angulated fractures require reduction and splinting; and displaced fractures (see the image below) require reduction and percutaneous pinning on an urgent basis within 12-24 hours.

Displaced supracondylar fracture. Displaced supracondylar fracture.

In adults, supracondylar fractures generally require surgery.

Extension-type

Ninety-five percent of supracondylar fractures are of the extension-type and are displaced posteriorly due to an extension force.

  • Type I fractures - Undisplaced

  • Type II fractures - Displaced with posterior cortex still intact

  • Type III fractures - Displaced with both anterior and posterior cortex disrupted

Management of type I fractures consists of immobilization with the elbow in flexion, while type II and II are generally treated by closed reduction followed by pin fixation.

Type III fractures have significant displacement and have a high incidence of neurovascular injury and therefore require urgent orthopedic consultation in the ED.

Open reduction is reserved for vascular insufficiency with a probable entrapped brachial artery in the fracture site or an irreducible fracture.

Flexion-type

Five percent of supracondylar fractures are of the flexion-type and have anterior displacement due to a flexion force.

The mechanism usually involves direct anterior force with anterior displacement of the distal fragment.

Open fractures are relatively common due to the direct force.

  • Type I fractures - Undisplaced

  • Type II fractures - Displaced with anterior cortex still intact

  • Type III fractures - Displaced with both anterior and posterior cortex disrupted and distal fragment migrants anteriorly and proximately

Treatment of type I fractures is simple immobilization in the flexed position.

Treatment of type II and III fractures should be referred to an orthopedist emergently and is often reduced to an extension position and requires surgical management.[1]

Medial epicondyle fracture

Fractures of the epicondyles are considered extra-articular.

Medial epicondyle fractures are usually in children as an avulsion type injury (see the image below).

Medial epicondyle fracture. Medial epicondyle fracture.

Mechanisms include posterior elbow dislocation, throwing a baseball (Little League elbow), or a direct blow.

Edema and pain over the medial elbow is common.

Nondisplaced or minimally displaced medial epicondyle fractures are treated nonoperatively.

Fragment displacement greater than 1 cm or valgus instability is often treated with internal fixation.

Rarely, entrapment of the medial epicondyle can occur between the trochlea and the coronoid process of the ulna; this can be mistaken for the ossification center of the trochlea.

ED management consists of immobilization of the forearm in flexion and pronation and the wrist in flexion.

Lateral epicondyle fracture

Lateral epicondyle fracture is very rare and is usually due to an avulsion fracture.

Fracture of the lateral humeral epicondyle can be mistaken for the radiolucency of the epiphysis.[8]

Treatment is immobilization with the elbow flexed to 90 degrees and the forearm in supination.[8]

Medial condyle fracture

Medial condyle fracture is rare and is usually found in children.

The mechanism is a fall on outstretched hand or excessive valgus stress.

This injury is often confused with medial epicondyle fractures.

Minimally displaced fractures are usually casted, whereas fractures with greater displacement usually require open or closed reduction with pin fixation.[8]

Lateral condyle fracture

Lateral condyle fracture is usually found in children and is the second most common pediatric elbow fracture.[9] See the image below.

Lateral condyle fracture. Lateral condyle fracture.

The mechanism is a blow to the lateral elbow or from varus stress.

Minimally displaced fractures are usually casted, whereas fractures with greater displacement usually require open or closed reduction with pin fixation.[9]

Intra-articular Fracture Patterns

Trochlea fracture

Isolated trochlea fractures are rare and are usually associated with other elbow injuries.

Nondisplaced fractures are usually managed with a posterior splint, whereas displaced fractures require surgical management.[8]

Capitellum fracture

Isolated capitellum fractures are rare as they often occur in posterior elbow dislocations or with radial head fractures.

They are usually due to a fall on an outstretched hand.

Surgical repair is often indicated.

Radial head fractures

Radial head fracture is the most common of all fractures of the elbow and associated injuries are common. See the image below.

Radial head fracture. Radial head fracture.

The mechanism is usually a fall onto an outstretched hand.

Radial head fracture is characterized by point tenderness at the radial head (located along the lateral aspect of the elbow) and pain with pronation/supination.

A specific associated injury, the Essex-Lopresti lesion occurs when the radial-ulnar interosseous membrane is disrupted, causing distal radioulnar joint dissociation.

Careful examination of radiographs is important because fractures may be subtle.

For nondisplaced fractures, a sling with the elbow in flexion is usually adequate.

With displaced radial head fractures, patients can be placed in a posterior long-arm splint with the elbow in 90° of flexion and the forearm in full supination and placed in a sling for comfort.

Olecranon fractures

The mechanism is usually a direct blow or a fall onto an outstretched hand. See the image below.

Olecranon fracture. Olecranon fracture.

The fracture line is usually transverse, passing into the trochlear notch.[8]

Patients demonstrate an inability to extend the elbow actively, along with point tenderness at the olecranon.

Ulnar nerve injury is common.

Patients can be placed in a well-padded, long-arm posterior splint with the elbow in 70° of flexion and the forearm neutral with respect to pronation/supination.

Nondisplaced fractures are usually managed conservatively, whereas all others often require surgical repair.

Epidemiology

Age

Fracture patterns vary markedly among different age groups.

Supracondylar fractures are the most common elbow fracture in children because of the relative strength of surrounding ligaments in comparison to bone.

Radial head fractures are the most common elbow fracture in adults.

 

Presentation

History

Mechanism of injury for most elbow fractures is direct elbow trauma or a fall onto an outstretched hand. Patients may experience the following:

  • Pain

  • Swelling

  • Decreased range of motion

Physical

A thorough neurovascular examination is vital in the assessment of elbow fractures because of the high incidence of neurovascular injuries with elbow fractures and the subsequent long-term complications with these injuries.

With supracondylar fractures, the incidence of anterior interosseous nerve injury is high, and specific muscle testing of flexion at the distal interphalangeal joint of the index finger should be performed.[10]

Patients often have decreased range of motion, and pain is present with pronation/supination of the forearm.

Edema and ecchymosis near the elbow may be evident.

Perform careful shoulder and wrist examinations with all elbow injuries.

 

DDx

 

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.

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

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.

 

Treatment

Emergency Department Care

Emergency physicians need to do a thorough neurovascular examination as well as evaluate for concurrent injuries.

Provide adequate analgesia to achieve patient comfort in the ED.

Proper immobilization for the various types of elbow fractures is indicated.

Assess whether the patient needs orthopedic evaluation in the ED, admission to the hospital for observation, or if discharge and follow up with an orthopedic surgeon is adequate.

Consultations

All elbow fractures should be referred for orthopedic follow-up.

Urgent orthopedic consultation in the ED is required in the following situations:

  • If an open fracture or an open joint is suspected

  • If the injury poses a significant risk of neurovascular injury such as a displaced supracondylar fracture

 

Medication

Medication Summary

Drugs used to treat fractures are generally NSAIDs, analgesics, and anxiolytics. In addition, administer proper antibiotics and tetanus prophylaxis for open fractures.

Nonsteroidal anti-inflammatory agents (NSAIDs)

Class Summary

These drugs are used commonly for relief of mild to moderately severe pain. Effects of NSAIDs in treatment of pain tend to be patient specific, yet ibuprofen is usually DOC for initial therapy. Other options include flurbiprofen, ketoprofen, and naproxen.

Ibuprofen (Ibuprin, Advil, Motrin)

Usually DOC for treatment of mild to moderately severe pain, if no contraindications. Inhibits inflammatory reactions and pain, probably by decreasing activity of enzyme cyclooxygenase, which inhibits prostaglandin synthesis.

Naproxen (Anaprox, Naprelan, Naprosyn)

Used for relief of mild to moderately severe pain. Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, which decreases prostaglandin synthesis.

Analgesics

Class Summary

Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients with fractures.

Hydrocodone bitartrate and acetaminophen (Vicodin ES)

Drug combination indicated for relief of moderately severe to severe pain.

Oxycodone and acetaminophen (Percocet)

Drug combination indicated for relief of moderately severe to severe pain. DOC for aspirin-hypersensitive patients.

Anxiolytics

Class Summary

Patients with painful injuries usually experience significant anxiety. Anxiolytics allow a smaller analgesic dose to achieve the same effect.

Lorazepam (Ativan)

Sedative hypnotic in benzodiazepine class that has a short onset of effect and relatively long half-life. By increasing action of GABA, a major inhibitory neurotransmitter, may depress all levels of CNS, including limbic and reticular formation.

Excellent for sedating patient for longer than 24-h period.

Monitor patient's BP after administering dose and adjust as necessary.

Antibiotics

Class Summary

These agents are given as prophylaxis to patients with open fractures.

Cefazolin (Ancef)

Used along with gentamicin for prophylaxis in patients with open fractures. First-generation semisynthetic cephalosporin that by binding to 1 or more penicillin-binding proteins arrests bacterial cell wall synthesis and inhibits bacterial replication. Poor capacity to cross blood-brain barrier. Primarily active against skin flora, including S aureus. Typically used alone for skin and skin-structure coverage. IV and IM dosing regimens are similar.

Gentamicin (Gentacidin, Garamycin)

Aminoglycoside antibiotic used for gram-negative bacterial coverage. Commonly used in combination with both an agent against gram-positive organisms and one that covers anaerobes.

Dosing regimens are numerous and adjusted based on renal function (CrCl) and changes in volume of distribution. Dose may be given IV/IM.

Toxoid

Class Summary

This agent is used for tetanus immunization. Booster injection in previously immunized individuals is recommended to prevent this potentially lethal syndrome.

Tetanus toxoid adsorbed or fluid

Induces active immunity against tetanus in selected patients. Immunizing DOC for most adults and children >7 y are tetanus and diphtheria toxoids. Necessary to administer booster doses to maintain tetanus immunity throughout life. Pregnant patients should receive only tetanus toxoid, not a diphtheria antigen-containing product.

In children and adults, may administer into deltoid or midlateral thigh muscles. In infants, preferred site of administration is midthigh, lateral.

Immunoglobulins

Class Summary

Patients who may not have been immunized against Clostridium tetani products should receive tetanus immune globulin.

Tetanus immune globulin (TIG)

For passive immunization of any person with a wound that may be contaminated with tetanus spores.

 

Follow-up

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.

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.

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

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 the image below).

Cubitus varus. Cubitus varus.

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 post-traumatic arthritis of the elbow.

Most operative and nonoperative cases of olecranon fracture have a good outcome with no long-term deficits.

Patient Education

For patient education resources, see the Breaks, Fractures, and Dislocations Center, as well as Broken Elbow and Elbow Dislocation.

For more information, see Medscape’s Fracture Resource Center.