Assessment and management of fractures around the elbow in adults
by James Donaldson

SCENARIO: you are called to the Emergency department to assess a 20 year old who fell from a height onto his elbow. No other injuries.

HISTORY:

Age
Occupation – useful for deciding treatment
Handedness
Time/date of injury

Past medical/surgical history

Medication/drugs and allergies

Last ate/drank (for timing of emergency surgery if needed)

Immediate assessment:

Exclude all other injuries
Examine affected limb - look for obvious deformity and determine if open or closed injury. 
Examine radial/ulna/median nerves both motor and sensation. Palpate for a radial & ulna pulses. Assess capillary refill.
Investigations:

X-Ray of affected limb - true AP and lateral of elbow with images of joint above and below
  • Assess bony contours and presence of fractures / dislocations
  • Anterior fat pad sign is pathopneumonic for an intra-articular injury
  • The anterior humeral line should intersect the anterior third of the capitellum
  • The radial head and capitellum should line up on both views
Injury

Olecranon fracture







Radial Head Fractures




Elbow dislocation







Distal humerus fractures
Mechanism

Direct violence – fall on point of elbow or direct blow 
Indirect - fall on outstretched hand with elbow in flexion and contraction of triceps




Fall on outstretched hand, valgus loading or direct trauma



Fall onto extended elbow







High energy trauma or fall in adults
Signs & symptoms
  • Haemarthrosis of the elbow
  • In particular pain and swelling around the olecranon
  • Inability to extend the elbow actively indicates disruption of the triceps mechanism
  • Careful neurological exam - ulnar nerve injuries are possible


  • Pain and swelling
  • Tender radial head
  • Restricted supination more than flexion / extension

  • Deformed and swollen elbow
  • Neurovascular exam crucial prior to reduction
  • Median, ulnar, radial, anterior interosseous nerve, as well as the brachial artery can all be injured
  • Simple (no associated fractures) or complex (associated fracture)


  • Deformed, shortened and swollen elbow
  • Neurovascular examination is important
Olecranon fracture
  • Assess for comminution, degree of displacement and associated injuries (in particular radial head injuries)
  • Undisplaced - Immobilization in 45° to 90° of flexion and fracture clinic follow up
  • Displaced – Backslab and admit for surgery (tension band wiring or plate)
  • If open wound – lavage, commence antibiotics and admit for surgical management on next available list. Inform senior
Radial head fracture
  • Type I: undisplaced. Can be treated with early movement. Fracture clinic follow up.
  • Type II: marginal fractures with displacement. If there is more than 2mm of displacement or a mechanical block to movement surgery is indicated (ORIF). Backslab and admit or arrange early follow up for discussion of surgery
  • Type III: comminuted fractures of the whole head. If reconstruction is not possible replacement or excision are the best options. Backslab and admit
Elbow dislocation
  • Classified according to the direction of the distal component. Most are posterolateral.
  • Emergent closed reduction with analgesia and sedation:
  • traction with the elbow flexed and then forward pressure over the olecranon.
  • Place in backslab. Check X-ray afterwards. If satisfactory early follow up for repeat X-ray.
Call senior if:
  • Neurological compromise (up to 20%). Document before and after!
  • Compromised perfusion. Involve vascular surgeons early
  • Irreducible
  • Open reduction is rarely needed (occasionally the medial epicondyle can be trapped preventing reduction)
  • Terrible triad – radial head fracture, coronoid process fracture and dislocation has poor results
Distal humerus fracture
  • May be extra-articular, partial intra-articular or complete intra-articular
  • Classification is rarely useful
  • Backslab and admit
  • The elbow joint needs to be restored anatomically, usually with rigid internal fixation and early mobilization
  • Stiffness is a significant problem and most patients will lose some movement
  • If it is not reconstructable (too many pieces) a total elbow replacement can be performed although this is usually reserved for the elderly

Call senior if: Neurovascular compromise or open injury