Context

Elbow injuries are common and acute elbow trauma accounts for 2-3% of all visits to the
emergency department6.
It is important for the emergency physician to have a good knowledge of the elbow joint
and to be aware of the common injuries that occur. Injuries are common, both in adults
and children, but the fracture patterns in children tend to be different to the adult
population due to the nature of the developing bones.
An ability to interpret elbow radiographs is important to detect what may often be subtle
injuries. Paediatric radiographs, in particular, can be very difficult to interpret and are
complicated further by the gradual appearance of multiple ossification centres during
skeletal development.
This session aims to provide an introduction to the common acute traumatic injuries that
occur around the elbow joint, and to provide the emergency physician with an
understanding of the assessment and initial management of these injuries.
Learning bite
Elbow injuries are common in both adults and children although fracture patterns differ
between the two populations.
Anatomy
The elbow is a hinge joint and consists of the humero-ulnar, humero-radial and proximal
radio-ulnar articulations. The radial head articulates with the humeral capitellum whilst the
trochlear notch of the ulna articulates with the humeral trochlea. Posteriorly the ulna forms
the olecranon, which contacts the olecranon fossa of the humerus at full elbow extension.
Anatomy of the joint – The elbow joint allows from 00 to approximately 140-1500 of
flexion7.
Learning bite
The elbow is a hinge joint formed by the humerus, radius and ulna.
Hyperextension may be possible and up to 15 is considered normal, especially in women.
Movement at the proximal and distal radio-ulnar joints combine to produce 75 of pronation
and 80 of supination. When fully extended the elbow joint forms a valgus angle, this is
commonly referred to as the carrying angle and is generally greater in women.
Bony landmarks of the elbow palpable on examination are the:
• medial and lateral humeral epicondyles
• olecranon process and proximal ulnar shaft
• head of radius
Figure 1: Bony anatomy of the elbow
Ligaments
The lateral and medial collateral ligaments provide joint stability. The nearby annular
ligament attaches to the anterior and posterior margins of the radial notch on the ulna and
forms a collar around the radial head.
Figure 2: Elbow ligaments
Muscles
Elbow flexion results from the actions of the biceps brachii, brachialis, brachioradialis and
pronator teres muscles, which cross the joint anteriorly. The triceps tendon inserts into the
olecranon process posteriorly and together with the anconeus muscle is responsible for
elbow extension.
Figure 3: Muscles surrounding the elbow joint
Several muscles responsible for wrist and finger flexion have a common insertion into the
medial epicondyle (flexor carpi radialis, palmaris longus, flexor carpi ulnaris and flexor
digitorum superficialis). Similarly, several extensor muscles insert into the lateral
epicondyle (extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi and
extensor carpi ulnaris).
Learning bite
Several forearm flexor and extensor muscles insert at the elbow.
Nerves and arteries
The cubital fossa is a triangular depression found anterior to the elbow joint and contains
the median nerve, biceps tendon, brachial artery, and radial nerve (deep and superficial
branches). The ulnar nerve crosses the elbow joint posteriorly, running behind the medial
epicondyle in a groove adjacent to the olecranon. The olecranon bursa is located over the
posterior aspect of the olecranon.
Figure 4: Nerves and artery running across the elbow joint
Clinical Assessment :

Initial Assessment

The initial assessment of the patient presenting with an elbow injury should consist
of a history, the key points of which include the:
• Mechanism of injury (particularly important in paediatric injuries when non-
accidental injury should be considered)
 • Onset and location of pain
• Associated symptoms, including sensory disturbance and proximal or distal limb
pain
• History of previous elbow injury
Learning-bite
The history of the injury should be taken prior to examination.
Examination
Subsequently the examination route should follow the sequence of:
Look

This should also include the wrist and shoulder. Note any bruising, swelling or deformity.
The medial and lateral epicondyles, along with the olecranon, should form a straight line in
full extension and an equilateral triangle in flexion. Disturbance of this alignment should
raise the suspicion of a fracture or dislocation.
Learning bite
It is useful to note the alignment of the epicondyles and olecranon in both flexion and
extension.
Feel
The bony landmarks mentioned previously should be palpated (medial and lateral
epicondyles, olecranon and radial head).
Further palpation, particularly of the radial head, should occur during elbow movement.
Tenderness over the common flexor or extensor tendon insertions in the absence of a
history of acute trauma is suggestive of tendinopathy and can be confirmed with special
tests.
Learning bite
Careful palpation can help to identify the structure(s) likely to be injured.
Move
Passive and active range of elbow movement should be assessed and should include
flexion, extension, supination and pronation. It is important to compare both sides in order
to distinguish between normal and abnormal reduced range of movement.
Resisted elbow flexion and extension stresses the biceps and triceps tendons respectively
and increased pain on testing may suggest a musculotendinous strain.
Grossly reduced flexion or extension strength, accompanied with pain and localised
swelling/bruising, might suggest a rupture of the biceps tendon or avulsion fracture of the
triceps insertion.
Learning bite
Movement of both sides should be compared during the examination.
Special Tests
The medial and lateral collateral ligaments should be stressed with valgus and varus
forces across the joint in 30 degrees of flexion. Increased pain and/or laxity are suggestive
of ligamentous sprain.
Extensor tendinopathy

The common extensor tendon insertion should be palpated during resisted wrist extension
with the forearm pronated, increased pain is suggestive of extensor tendinopathy,
otherwise known as lateral epicondylosis or ‘tennis elbow’.
Flexor tendinopathy
Similarly, increased pain located at the common flexor tendon insertion during resisted
wrist flexion with the forearm supinated, is suggestive of flexor tendinopathy, also known
as medial epicondylosis or ‘golfer’s elbow’.
As with all musculoskeletal injuries the neurovascular status of the distal limb should be
assessed. Specifically median, radial and ulnar nerve sensory and motor functions should
be tested, along with palpation of the radial and ulnar pulses.

Investigation strategies:

Imaging
Figure 5: Normal elbow xray
Important Lines
Anterior Humeral Line
If a line is drawn along the anterior part of the humerus on the lateral radiograph, then it
should intersect the middle third of the capitellum. Failure to do this indicates that the
capitellum has been displaced. There is often posterior displacement in association with
supracondylar fractures.
Figure 6: Normal (left) and abnormal (right) anterior humeral line
The Radio-Capitellar Line
A line drawn through the middle of the radius should always bisect the capitellum since the
radial head articulates with the capitellum. This should occur in every direction, no matter
which x-ray view is taken. If this is not the case suspect dislocation of the radial head and
remember that this can sometimes be associated with ulna fractures (Monteggia fracture-
dislocation).
Figure 7: Normal (left) and abnormal (right) radio-capitellar line
Fat Pads
On a normal AP x-ray of the elbow an anterior fat pad is visible due to fat in the joint
capsule. It is never normal to see a posterior fat pad because this is hidden in the
intercondylar fossa. The diagram below shows a displaced anterior fat pad in association
with a posterior fat pad. This is known as the sail sign because of its resemblance to the
sails of a boat. In the setting of acute trauma it represents blood in the joint. In the non-
trauma setting effusion may be due to an inflammatory cause. Note that if the fracture is
extra-articular, then there may not be a joint effusion and therefore the fad pad sign will be
absent.
Examine the radial head closely in these injuries as there is often a subtle fracture.
Presence of a posterior fat pad has been associated with a 75% rate of occult fracture.
Learning bite
The anterior humeral line, radio-capitellar line and the presence or absence of fat pads can
aid x-ray interpretation.
Figure 8: Positive Sail Sign

Ossification Centres
There are six ossification centres in the elbow of a developing child and they occur in a
fixed order at sequential times up to the age of 13 years, although these times are
variable. It is the presence of these centres that make paediatric elbow x-rays notoriously
difficult to interpret. Knowledge of these ossification centres and the age at which they
appear will assist the observer in identifying whether a fracture is present or not. A well-
known helpful pneumonic for this is CRITOL or CRITOE:

Capitellum 1 year

Radial head 3 years

Internal (medial) epicondyle 5 years

 Trochlear 7 years

Olecranon 9 years

Lateral (External) epicondyle 11 years

Note that these ages vary but a broad guide of 1,3,5,7,9 and 11 years is easy to
remember.
Figure 9: Ossification centres

Contours
Finally, it is important to analyse all three bones of the elbow joint and follow the contours,
looking for irregularities and steps that could indicate subtle disruptions and fractures in
the cortex.
Common subtle injuries that may be difficult to identify include undisplaced radial head
fractures in adults and undisplaced supracondylar fractures in children. There may often
be other clues such as a positive fat pad sign (click on the x-ray to enlarge).
Clearly, the x-ray is an adjunct to your assessment and management should be based on
clinical findings and suspicion, rather than x-ray appearances alone.
Whenever a fracture is identified it is essential that the ipsilateral wrist is imaged along with
the entire radius and ulna, in order to exclude any associated fractures or dislocations.
Learning bite
It is important to interpret the x-ray in combination with examination findings.
The identification of a bony injury should prompt a search for other associated injuries.
This may require additional imaging.

Differential Diagnosis:

Elbow Dislocation
Elbow dislocation is seen in both children and adults and is usually caused by a fall onto
the outstretched hand. In children it is more common than dislocation of the shoulder [2].
Examination may reveal obvious deformity of the elbow. The triangular relationship of the
epicondyles and olecranon will be disrupted. It is important to check the distal
neurovascular status of the limb due to possible damage to the brachial artery or median
and ulnar nerves.
The dislocation is most commonly in a posterior or posterolateral direction and will be
confirmed on x-ray, along with the presence of any associated fractures. Associated
epicondylar fractures and fractures of the lateral condyle are known to occur in children.
Click on the x-rays to enlarge.
 Fig 1: This lateral view clearly Fig 2: The AP view of
demonstrates posterior dislocation of the same injury
the elbow. Note the associated illustrates some lateral
fracture fragment. displacement.

Other Fractures
Radial head fractures

Radial head injuries usually follow a fall onto an outstretched wrist or direct trauma. Radial
head fractures usually occur in adults and account for 30% of all adult elbow fractures [3].
The x-ray shows a displaced radial head fracture
Examination may reveal local bruising and swelling. In some cases pain may only be
evident with palpation of the radial head during passive forearm pronation. Elbow
extension is usually restricted.
Assessment of the wrist should be performed due to the possibility of an Essex-Lopresti
fracture-dislocation, consisting of a comminuted radial head fracture with subluxation of
the distal end of the ulna.
Radiography may reveal the fracture or merely the presence of a joint effusion.
Learning bite
Pain due to a radial head fracture may only be evident with palpation during passive
forearm pronation.
Olecranon fractures
With olecranon fractures the mechanism of injury is usually a fall onto the point of the
elbow or onto a semi-flexed outstretched forearm.
The x-ray shows a displaced olecranon fracture
Examination will reveal swelling and tenderness over the posterior aspect of the elbow.
Radiography will confirm the diagnosis and also reveal any displacement due to the pull of
the triceps tendon.
Identification of paediatric olecranon fractures may be complicated by the appearance of
the olecranon ossification centre, which may be bifid.
Learning bite
Care should be taken when attempting to identify or exclude a fracture in a child with an
olecranon ossification centre.
Monteggia fracture-dislocation
A Monteggia fracture-dislocation injury comprises of a dislocation of the radial head with
an ulna fracture. It may result from a direct blow to the ulna or forced pronation.
The x-ray shows a Monteggia fracture-dislocation with partially visible ulna shaft fracture.
The radiographic appearance of a dislocated radial head (suspect if a line bisecting the
radius longitudinally does not pass through the centre of the capitellum) should prompt
further imaging of the forearm to exclude an ulna fracture.
Learning bite
Radial head dislocation should raise suspicion of an associated ulna fracture.
Galeazzi fracture-dislocation
A Galeazzi fracture-dislocation injury consists of a radius fracture in combination with
dislocation of the inferior radio-ulnar joint at the wrist. The wrist joint should therefore be
imaged and closely inspected when a radial fracture is identified.
The x-ray shows a Galeazzi fracture-dislocation
The possibility of combined injuries such as those recognized by Galeazzi and Monteggia
illustrates the need to image the elbow, wrist and entire radius and ulna when one bony
injury is identified.
Learning bite
The presence of a radius fracture should raise suspicion of associated distal radio-ulna
joint dislocation.
Differential Diagnosis (Paediatric)
Supracondylar Fractures
Supracondylar fractures account for 60% of all paediatric elbow fractures and typically
follow a fall onto an outstretched hand. The peak incidence occurs between the ages of
five and eight years [4].
Children are more prone to supracondylar fractures than adults due to the relatively thin
trabeculae of the coronoid and olecranon fossae in this section of the population. Ninety
percent of these fractures are caused by hyperextension injury due to ligament laxity. The
force is transmitted up through the ulna and into the distal humerus.
Learning bite
Supracondylar fractures are most commonly due to a hyperextension injury.
Signs to look out for on x-ray include presence of fat pads and loss of normal anterior
humeral alignment. Undisplaced fractures may only be identified by subtle disruption in the
posterior cortex whereas displaced fractures will normally be obvious.
Other Injuries
Lateral condyle fracture

Fractures of the lateral humeral condyle are the second most common elbow fracture seen
in children, usually between the ages of four and ten [4].
The x-ray shows a displaced lateral condyle fracture.
It results from a varus force applied through the extended elbow, normally due to a fall
onto an outstretched hand. It is commonly displaced by the action of the forearm
extensors.
Appearance on x-ray may be subtle so an awareness of the possibility of this injury is
necessary when interpreting films.
Learning bite
The radiographic appearance of lateral condyle fractures may be subtle.
Medial epicondyle avulsion injury
Medial epicondyle avulsion injuries tend to occur in adolescents due to valgus stress
during a fall on an outstretched hand. There may be associated ulna nerve damage and
sometimes dislocation.
The x-ray shows an avulsion of the medial epicondyle.
Radial neck fracture
Radial neck fractures are more common in children due to weak metaphyseal bone and,
as with radial head fractures, may be difficult to spot on an x-ray [4].
The x-ray shows a radial neck fracture
Pulled elbow
Pulled elbow is also sometimes known as ‘nursemaid’s elbow’. This injury is seen most
commonly in children aged one to five years [4]. There is often a history of traction on the
arm of the child although this is not always the case. In some cases the parent may not be
willing to volunteer the history or may not have been present when the injury occurred. The
child will not be using the arm.
Pulled elbow results from subluxation of the radial head from its normal position encircled
by the annular ligament.
Learning bite
A pulled elbow should be suspected following a history of traction to the arm.
Differential Diagnosis (Soft Tissue)
Lateral epicondylosis
Lateral epicondylosis is also known as ‘tennis elbow’.
This condition often occurs as a result of overuse of the forearm extensor tendons.
Previously known as lateral epicondylitis, the pathological process is thought to be due to
failed tendon healing and degeneration rather than acute inflammation.
The patient may complain of a diffuse ache located over the lateral aspect of the elbow.
The diagnosis can be made clinically as illustrated previously – the image illustrates
assessing for common extensor tendon insertion tenderness.
Learning bite
Lateral epicondylitis is often due to overuse of the forearm extensor tendons.
Medial epicondylosis
Medial epicondylosis is also known as ‘golfer’s elbow’.
This condition is seen less commonly than lateral epicondylosis and is similarly often
caused by overuse, this time of the forearm flexor tendons, giving rise to pain over the
medial aspect of the elbow.
In 20% of cases there may be associated ulnar nerve symptoms, specifically paraesthesia
in an ulnar nerve distribution [5]. The diagnosis should again be made clinically.
Learning bite
Medial epicondylosis is often due to overuse of the forearm flexor tendons.
Olecranon bursitis
Olecranon bursitis is usually the result of direct trauma (such as a fall onto the
outstretched elbow) or repetitive friction. It may be acute or chronic and can be associated
with crystal arthropathy or inflammatory arthritis. Septic bursitis is most commonly due to
Staphylococcus aureus infection and can arise directly from an overlying skin wound.
On examination there is localised swelling, tenderness and possible erythema over the
posterior aspect of the elbow. Patients with septic bursitis may be systemically unwell with
pyrexia, cellulitis and axillary lymphadenopathy.
Blood tests may reveal an elevated ESR, CRP and white cell count. Septic or crystal-
induced bursitis can be confirmed with bursal aspiration and subsequent microscopy and
Gram stain.

Management

The procedure for the management of elbow dislocations includes:

Analgesia
Analgesia should be provided prior to attempts to reduce the dislocation. Reduction using
short-acting analgesic agents such as Entonox or Penthrox may be possible but in some
cases reduction using procedural sedation or even reduction under general anaesthetic
may be required.
Fig. 10: Posterior elbow dislocation
Reduction techniques
Several techniques for reduction of a posteriorly dislocated elbow are recognised:
 Fig A: With the Fig B:
elbow flexed to Lever the Fig C: Position the patient
60 degrees olecranon prone with the abducted
provide traction to forwards humerus resting upon the
the pronated whilst bed and pronated forearm
forearm and traction is hanging towards the floor.
counter-traction being Provide traction to the
to the distal provided to forearm and downward
humerus the pressure to the olecranon
forearm
Post reduction
Reduction should be immediately followed by a further assessment of limb neurovascular
status. Successful reduction is then confirmed by repeat x-ray. This will also enable
assessment of the new position of any associated fractures.
The reduced elbow can be immobilised in a sling or splint in 90 degrees of flexion. In
cases where there are concerns over neurovascular impairment or significant elbow
swelling a period of observation should follow. This is due to the possibility of compartment
syndrome developing in the forearm fascia or biceps tendon. Outpatient orthopaedic
review should subsequently be arranged. Myositis ossificans may later develop as a result
of large elbow haemarthroses.
Learning bite
Post-reduction assessment of neurovascular status and repeat x-ray is essential.
Other Fractures
Other fractures can be managed in the following ways:
Radial head fractures
Undisplaced radial head fractures can be managed with a collar and cuff sling and
orthopaedic outpatient follow-up.
Further management generally consists of early mobilization to prevent loss of elbow
extension. Comminuted or displaced fractures may require manipulation under anaesthetic
or internal fixation. Occasionally the radial head may need to be excised and replaced.
Radial neck fractures are seen more commonly in children and are managed similar to
radial head fractures. Greater than 20 degrees of angulation in the adult requires
reduction.
Figure. 11 Radial head fracture

Olecranon fractures
Undisplaced olecranon fractures can be managed with a back slab in 90 degrees of elbow
flexion and orthopaedic clinic follow-up.
Displaced fractures (>2mm) and those with comminution are more likely to require
operative fixation and therefore warrant orthopaedic referral.
Learning bite
Undisplaced radial head and olecranon fractures may be managed conservatively.
Figure. 12 Olecranon Fracture
Monteggia fracture-dislocation
Monteggia fracture-dislocation injuries should be referred for reduction and internal
fixation.
 
Paediatric Injuries
Figure 13: Type 2 Supracondylar fracture with posterior fat pad
 
 
 
 
 
 
 
 
The procedure for the management of paediatric supracondylar fractures includes:
Analgesia
Initial assessment should include provision of analgesia and a search for associated
neurovascular complications.
Intranasal administration of analgesia (diamorphine) is a useful option in children and can
delay attempts at intravenous access until topical anaesthesia has taken effect.
Treatment
Undisplaced fractures may be treated with a collar and cuff and can be followed up in
fracture clinic. If there is significant pain, a back slab may be a better option.
Displaced fractures should all be referred for manipulation, urgently if circulation is
compromised.
Complications
Complications include:
• Cubitus varus (gun stock deformity)
• Malunion and stiffness
• Myositis ossificans
• Nerve injury (most commonly the median nerve)
• Brachial artery (due to stretch and posterior displacement)
• Volkmann’s ischaemic contracture (due to compartment swelling)
Other paediatric injuries can be managed in the following ways:
Lateral epicondyle epiphyseal injury
Undisplaced fractures can be managed in a back slab with orthopaedic follow up.
Displaced fractures often need reduction.
Fig. 14: Lateral epicondyle avulsion

Medial epicondyle avulsion injury

Undisplaced avulsions can be managed conservatively.
Displaced fragments should be referred for reduction.
Radial neck fracture
Treatment is similar to that for radial head fractures:
• Undisplaced fractures can be managed with a collar and cuff sling and orthopaedic
outpatient follow-up
• Comminuted or displaced fractures may require manipulation under anaesthetic or
internal fixation
Orthopaedic referral is recommended if there is greater than 30o of angulation.
Pulled elbow
The x-ray would appear normal and is therefore not necessary prior to attempted
manipulation if clinical suspicion is high.
Traditional reduction is achieved by flexing the elbow to 90o and then fully supinating or
pronating the forearm, there may often be an associated click and the child will begin using
the arm a short time later.
Learning bite
A pulled elbow can be quickly and easily treated in the emergency department with
passive supination/pronation of the forearm.
Soft tissue injuries
Lateral epicondylosis / Tennis elbow
This condition occurs as a result of overuse of the forearm extensor tendons. Previously
known as lateral epicondylitis the process is thought to be due to failed tendon healing
rather than acute inflammation. The patient may complain of a diffuse ache located over
the lateral aspect of the elbow. The diagnosis can be made clinically as described
previously.
Management should consist of advice regarding relative rest, ice therapy and analgesia.
The condition is often persistent and although corticosteroid injection reduces pain the
effects do not appear to last beyond six weeks.
Physiotherapy has an established role, although results at 12 months are comparable with
patients who have not received any intervention.
Medial epicondylosis / Golfers elbow
This condition is seen less commonly than lateral epicondylosis and is similarly an overuse
injury, this time of the forearm flexor tendons, giving rise to pain over the medial aspect of
the elbow. In 20% of cases there may be associated ulnar nerve symptoms, specifically
paraesthesia in an ulnar nerve distribution. The diagnosis should again be made clinically.
Management should follow that for lateral epicondylosis.
Olecranon bursitis

Treatment is with relative rest, ice therapy and analgesia. A broad arm sling may be
required in more severe cases.
Septic bursitis requires antibiotics (intravenous if systemically unwell) as per local policy.
Caution is required when considering aspiration of olecranon bursae since fistula formation
is a widely recognised complication of the procedure.

Safety pearls and Foot falls:

• A subtle fracture may be missed if insufficient attention is paid to the appearance of

an elevated anterior fat pad
• Radial head dislocation may not be obvious and should be excluded with use of the
radio-capitellar line
• A minimally displaced supracondylar fracture may not be obvious and should be
excluded with use of the anterior-humeral line
• Misinterpretation of the paediatric elbow x-ray may result from a lack of knowledge
of the appearance of ossification centres
• Associated injuries may be missed if the identification of one bony injury does not
prompt a search for others with further radiography
• Neurovascular compromise may be associated with supracondylar fractures and
elbow dislocations and should always be assessed