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Elbow Injuries and Fractures

The humerus of the upper arm and the paired radius and ulna of the forearm meet to form the elbow joint, a hinge joint in the upper arm. The bony prominence at the tip of the elbow is the olecranon process of the ulna. The antecubital fossa lies over the anterior aspect of the elbow. Injuries to the elbow are common and often accompanied by injury to shoulder or wrist joints. It is important to assess injuries promptly and accurately taking into account age and the mechanism of injury, particularly because of the risk of accompanying vascular involvement. In addition to injuries listed in the table below, see also separate articles forearm injuries and fractures (deals with Monteggia's fractures), pulled elbow (nursemaid's elbow), tennis elbow andolecranon bursitis.

The mechanism of injury
There are a variety of possible injuries because of the presence of three bones and the variety of mechanisms of injury.

Mechanism of injury in elbow fractures and dislocation Radial head and neck fractures Olecranon fractures Fall on to an outstretched hand

 

Elderly - indirect trauma by pull of triceps and brachioradialis Children - direct blow to elbow

Fractures of the coronoid process Fractures of the distal humerus Intercondylar fractures Condylar fractures Capitellum fracture Elbow dislocation

Fall on to extended elbow as for elbow dislocation

Fall on to extended outstretched hand

Direct or indirect blow to elbow Direct blow to flexed elbow Fall on to outstretched hand or direct trauma
 

Fall on to extended elbow Common in sport in the young

Radial head and neck fractures
Mechanism of injury

especially with brachial artery. This often needs aspiration of the haemarthrosis with instillation of local anaesthetic for pain relief. dislocation or evidence of nerve or vascular involvement.  There may be an associated ulnar shaft fracture (equivalent to adult Monteggia's fracture).  If there is significant wrist pain and/or central forearm pain.  It is important to detect a mechanical blockage of motion from displaced fracture fragments. However. Olecranon fractures Mechanism of injury These are low-energy fractures which occur most commonly in the elderly and result from indirect trauma caused by a sudden pull of the triceps and brachioradialis muscles.These are most commonly caused by a fall on to an outstretched arm. give sufficient analgesia and consider joint aspiration and instillation of anaesthetic as described above (usually in expert hands).  Presence of severe crepitation or complete blockage of motion for full extension and flexion shows presence of displaced fragments. Clinical features  The patient presents with swelling over the lateral elbow with limited range of motion.  Complex fractures require open reduction and internal fixation. in younger patients. .  Findings may be quite subtle and the only clue may be the fat pad sign (triangular radiolucent shadows anterior and posterior to the distal humerus on lateral X-ray. Management  Refer for urgent surgical treatment if there is elbow fracture. there may be acute longitudinal radioulnar dissociation with disruption of the distal radioulnar joint. Pain is increased with passive rotation. Radial head fracture is the most common fracture around the elbow joint in adults. monitor for displacement and institute active range of movement exercises.  The most reliable clinical sign is point tenderness over the radial head. median and ulnar nerves. In children  Can be difficult to diagnose. Investigations  AP and lateral X-ray views of the elbow are usually sufficient. including rotation.  Needs careful assessment for nerve and vascular involvement. Images of radial head fractures.  Immobilise the elbow in a long arm posterior splint with the elbow at 90°.often associated with intraarticular skeletal injury). flexion and extension at least 3-4 times daily. particularly forearm rotation and elbow extension ± elbow effusion and bruising. whereas radial neck fractures occur more commonly in children. and there may be an associated ulnar shaft fracture. indicating haemarthrosis and displacement of intra-articular fat pad .  Otherwise. olecranon fractures usually follow a direct blow to the point of the elbow and are often comminuted.  In non-displaced fractures. Clinical features  The patient presents with swelling and tenderness over the olecranon with haemarthrosis and limited range of motion. remove the posterior splint and replace with a sling for comfort only. as radial head ossification does not occur until age 4.  Ultrasound or MRI scanning may be needed to confirm the diagnosis.  Image of elbow fat pad sign.

 Flexion and extension exercises after 2 weeks.  Images of transcondylar fracture and its repair.  If still stable. There is an inability to extend the elbow against gravity.  AP and lateral X-rays of the elbow. splint for 5-7 days.  Immobilise the elbow in a long arm posterior splint with the elbow at 90° to the forearm in neutral rotation. Fractures of the distal humerus Mechanism of injury  Supracondylar/transcondylar .  Undertake careful examination for neural or vascular involvement due to risk of damage to the brachial artery and nerve.  True lateral X-ray of the elbow should reveal the fracture. Management  Immobilise the elbow in a long arm posterior splint with the elbow in 60-90° flexion.  Check strength of the radial pulse with the elbow at 90°. In non-displaced fractures.  Marked swelling of the forearm or palpable induration of forearm flexors.  There is a need to check for ulnar nerve damage and examine distal pulses. Management  All but non-displaced or minimally displaced fractures without neural or vascular involvement should be referred for surgical repair.  Transcondylar fractures are more common in the elderly.  Support the arm with collar and cuffs or a standard arm sling.  Refer displaced fractures for surgery.  Lateral X-ray of the elbow to show coronoid fracture. remove and repeat X-ray to confirm non-displacement. using a sling or removable posterior splint for comfort.  Displaced fractures or those involving >50% of process need surgical repair. . well moulded posteriorly.most are extension-type injuries from a fall on to an outstretched arm. suggests acute volar compartment syndrome requiring emergency fasciotomy. indicating dysfunction of the triceps lever. with pain on passive extension of the fingers. Clinical features  The patient usually presents with elbow swelling and pain. Management  Non-displaced fractures should be immobilised in a long arm posterior splint with the elbow at 90° and the forearm in full supination. start active range of movement exercises using a sling for comfort. gentle supination and pronation exercises are appropriate. Fractures of the coronoid process Mechanism of injury The mechanism of injury is as for elbow dislocation and such fractures are associated with elbow dislocation in about 40% of cases Clinical features  Patients present with tenderness over the antecubital fossa and swelling about the elbow. After 3 weeks.  Supracondylar fractures are more common in children.

Management  Most fractures require surgery because they are displaced.  Rarely.  AP and lateral views of intercondylar fracture. Mechanism of injury Commonly caused by a direct or indirect blow to the elbow. and ice and elevation are important in reducing swelling.  The injured forearm may appear shortened. . as above.  After 2 weeks. Clinical features  Patients usually present with swelling.  Re-examine within 24-48 hours. patients should remove the splint and perform gentle exercises. extend the elbow to the point where pulses return.  Crepitus with motion is frequently present.or Y-shaped fractures with varying displacement between the condyles and the humerus.  Lateral fractures are usually due to direct impact on a flexed elbow. limited range of movement and tenderness over the injured condyle.  Medial fractures are due to impact to the olecranon with flexed elbow. Capitellum fracture Mechanism of injury These fractures are usually caused by a fall on to the outstretched hand or by direct trauma. Management  Aspiration of joint haemarthrosis relieves discomfort.  Images of capitellum fracture.  Frequent checking of neural and vascular function is essential during the first 7-10 days. Clinical features  The patient usually presents with marked tissue swelling holding their forearm in pronation.  Refer for orthopaedic opinion. continuing to use a splint for approximately 6 weeks.  Present with anterior elbow pain and effusion.  Sudden adduction or hyperextension may also cause these fractures.  Crepitus of movement may be felt when condyles are pressed together.  Undisplaced fractures can be treated with a long arm posterior splint with the elbow at 90°. Check distal pulses after the splint has been applied and. non-displaced fractures can be treated similarly to non-displaced supracondylar fractures. Clinical features  These fractures involve the distal humeral articular surface.  AP and lateral X-rays reveal a widened intercondylar distance and there may be displaced fracture fragments.  Displaced fractures require surgical correction.  Lateral and AP radiography usually reveals the fracture. if absent. Intercondylar fractures These are T. Condylar fractures Mechanism of injury  Lateral condyle fractures are more common than medial. and then starting vigorous exercises.

hang a 2½-10 kg weight from the wrist or apply gentle longitudinal traction.  They are classified according to position of the ulna in relation to the humerus after injury. Repeat X-ray and immobilise the elbow in a posterior splint with the elbow at 90°.  Image of lateral view of posterior dislocation. Clinical features  Often associated with injury to brachial artery and nerve.  The patient usually presents with severe pain with the elbow flexed and swelling and deformity apparent. Mechanism of injury  Often due to a fall on to an extended elbow.  AP and lateral X-rays of the elbow to confirm dislocation and exclude fractures. median and ulnar nerve function. o After reduction. so undertake full examination of distal pulses.  Posterior dislocation: o First try countertraction on the humerus while applying longitudinal traction on the wrist and forearm. applying posterior and downward pressure to the forearm whilst applying anterior pressure from behind to the distal humerus. place the patient face down with the elbow hanging off the side of the table and place a small pillow under the humerus just proximal to the elbow joint. Management: undisplaced fractures may be splinted but more usually they are displaced and require surgical fixation.  Those without fracture are termed simple. Elbow dislocation Elbow dislocation is very common especially in young people undertaking sport. test joint mobility and stability and check neural and vascular function. o Continue distal traction as the elbow is flexed. o If this fails. This is usually performed under IV sedation and with adequate analgesia.  Anterior dislocation: o Basically the reverse of the above. Management  Prompt reduction is essential. o Usually reduces within several minutes but may need forward pressure on the olecranon. whereas dislocations with fracture are termed complex. o May need downward pressure on the proximal forearm. .

bone of the upper arm. In this situation the elbow joint needs to be reduced. Additional damage to the nerves and blood vessels of the . Below is an overview of the most common causes of elbow pain likely to be encountered by the mountaineer. an x-ray is required to determine a possible fracture. It is an important joint for range of motion and mobility of the upper extremities.2]. Pain is typically well localized and a mechanism of injury is apparent. Elbow Dislocation One of the most serious acute elbow injuries is an elbow dislocation. An x-ray is also required since the climber may have also suffered a fracture of the olecranon and/or radial head in this situation [1. The elbow may also appear deformed. Acute trauma to the elbow is likely to involve a fracture. RN. Pain with elbow flexion may indicate a fracture to the distal humerus. As compared to the wrist and shoulder.Common Elbow Injuries By Anne C. and the radius and ulna of the forearm. Surgery is often required for a fracture that is severely displaced. bruising and potential joint deformity. swelling. Acute Elbow Injuries Acute injuries to the elbow are generally recognized as less than 2 weeks in duration and may or may not be associated with direct trauma. dislocation or tendon rupture. Terry. ARNP Climbers are likely to encounter an elbow injury of some form in their mountaineering career. Elbow Fracture Fractures of the elbow also cause acute pain. The elbow joint is the center of articulation between the humerus. Since the patient likely needs sedation and pain management. MSN. most commonly as a result of a contact sport or fall from a height. This article is intended to be informative and is not a substitute for medical evaluation. Direct trauma or a fall on an outstretched hand may indicate an olecranon (proximal ulnar) fracture. In these scenarios. The patient experiences an immediate loss of range of motion in combination with acute pain over the elbow surface. or the joint needs to be put back in alignment. The climber may experience swelling. Fractures of the radius often occur over the radial head (at the elbow joint) and are associated with elbow dislocations. Typically this results from falling on an outstretched or extended arm. the elbow provides less weight bearing activity. Elbow fractures need to be recognized and treated early to minimize long term complications such as loss of elbow range of motion and chronic stiffness. bruising and/or loss of elbow function. the reduction should only be performed by a medical provider at an emergency clinic.

Patients may complain of numbness or tingling of the digits of the forearm or hand indicating potential nerve damage. PA often follows a history of a fracture. blood and serous fluid collect in this subcutaneous structure. Chronic Elbow Injuries Chronic elbow injuries are typically the result of repetitive injuries. However.2]. The condition can be either inflammatory. . The hallmark of biceps tendon rupture is the sudden contraction of the biceps muscle. They are recognized as greater than 2 weeks in duration. older athletes may elect not to repair this injury [1]. Biceps Tendon Rupture Typically. Bursitis describes the inflammation of the bursa.upper extremities may also be apparent. general inflammatory conditions and/or post trauma. dislocation or cartilage injury and results in recurrent pain. stiffness and/or loss of elbow range of motion. RA often presents with pain and symmetrical swelling of multiple joints. Arthritis Arthritis describes chronic joint pain. may precede this condition. Patients with OA often experience a feeling of locking or catching in the joint which is related to loose cartilage pieces. Joint deformity may occur [1. such as ibuprofen. It is caused by chronic overuse of the joint. OA is the result of calcification of cartilage in the joint spaces. previous injury or infection. postraumatic arthritis (PA) and rheumatoid arthritis (RA). infectious or both. there is minimal pain in these individuals after the tear. aleve. a rupture of the biceps tendon occurs in the older athlete. Occurring most often in older age. Initial treatment involves use of NSAIDS (non-steroidal anti-inflammatory agents. stiffness and restricted range of motion. Sharp pain and the sensation of muscle tearing often occur after repetitive lifting or acute injury. People often encounter this condition after leaning on the elbow surface for long periods of time. Patients often describe recurrent pain. Typically. acute episode of trauma to the tip of the elbow. this condition is also known as miner’s elbow. the connective tissue structure surrounding the joint space. Injury to the blood vessels may decrease perfusion to the forearm and hand as indicated by diminished temperature and/or a weakened or absent pulse at the wrist [1. Often. OA is characterized by pain.2]. The olecranon region often appears red and is warm to palpation. The most common forms encountered in the elbow include osteoarthritis (OA). A single. Olecranon Bursitis Acute or chronic swelling over the tip of the elbow with increased pain during movement is a sign of the development of olecranon bursitis. Surgery is usually required for reattachment of the tendon. stiffness and/or limited motion. such as a fall on a hard surface.

It causes inflammation in the forearm flexor muscles and the pronator teres tendon. is a chronic condition that occurs when the tendon is never allowed adequate time to heal properly. Fluid collection over the olecranon is easily infected with a simple abrasion. In severe cases. steroid injections are considered for refractory cases.2]. Treatment modalities are similar to that of lateral epicondylitis and also involve neural stretching to prevent damage to the ulnar nerve that courses across the medial elbow surface [3]. the region is aspirated to drain infected fluid and perform a bacterial culture. often known as golfer’s elbow and biceps tendinitis [3]. Biceps Tendinitis Inflammation of the biceps tendon results in pain over the anterior aspect of the elbow and is associated with recurrent flexion of the biceps muscle. or septic arthritis can occur [1. and can linger for months to even years. this condition is the result of chronic wrist flexion. Lateral Epicondylitis (LE) Lateral epicondylitis is a result of microscopic tears and scarring of the extensor carpi radialis brevis tendon located on the lateral (outer) aspect of the elbow. medial epicondylitis. Further treatment with antibiotics and immobilization is required. If unsuccessful. Pain is localized over the medial (inner) aspect of the elbow and is increased with wrist flexion. often known as tennis elbow. Each condition is usually the result of repetitive motion injuries to the elbow joint. These include lateral epicondylitis. such as high voltage stimulation or laser treatment. while using a computer mouse. If infection is suspected. such as with dips and bench pressing. and/or stretching. Treatment modalities include electrotherapeutic modalities. Climbers tend to experience ME more frequently than LE. on the other hand. Modifications to both job and sport activities may also be needed. surgery may be required to excise degenerative tissue causing the discomfort. or painting a ceiling) may overuse the forearm flexors. inflammation of a tendon. Overuse of the elbow caused by repeated wrist extension against resistance results in lateral pain. massage. insect bite or cut. Tendinitis There are three main forms of tendinitis. performing a back hand. NSAIDS. Climbers who repeatedly return to the climbing wall too soon can suffer from this chronic state for life. Tendinosis. such as osteomyelitis.naprosyn) to control inflammation and swelling. more serious infections. Muscle strengthening involving the wrist extensor is important for repair [3]. encountered in the elbow. Without treatment. Medial Epicondylitis (ME) Also known as golfer’s elbow. Patients present with local tenderness over the biceps . although anyone who must hold the wrist still and extended backwards for long periods of time (i.e. bone infection.

He then proceeded to fall a few more feet. IN: Essentials of Musculoskeletal there may also be chronic thickening of the tendon with muscle tightening of the biceps [2]. McGraw-Hill Book Company. J Am Acad Orthop Surg 1994 Jan. Elbow Pain. second edition. References 1. Australia. This case shows that not all acute injuries result in severe pain. At the time. This was especially pronounced with activities such as throwing a rope. Mark was doing an ice climb on the Nisqually glacier. He was placed in an immobilization splint for a few weeks and continues with physical therapy. Elbow and Forearm Pain. 2. Mark will concentrate on glacier and alpine climbs this year with minimal rock and ice work. Ciccotti. In fact. 164-197. P. he began to notice intense pain in the elbow and shoulder with specific movements such as lateral and overhead movements of the arm. Anne Terry is a nurse practitioner at the University of Washington with interests in orthopedics. Mark graciously accepted my offer for an interview. Brukner. However. A few months after the injury. Treatment involves use of NSAIDS. 3. Khan. he sought the care of an orthopedist who diagnosed 2 separate tears in the biceps tendon. deformity or loss of motion. MG. I talked with a fellow intermediate student who had recently suffered an injury to the arm while ice climbing. Case Study While teaching at rock 2 on Mt Erie this year. p. p. as well as local massage therapy and limiting activity. Lateral and Medial Epicondylitis of the Elbow. Jobe.tendon. 2(1): 1-8 . he had some mild aching over the upper arm and anterior shoulder and felt this was likely a mild muscular strain or bruise. He slipped and began to fall placing all of his weight temporarily on his outstretched left arm. 274-291. He was top roped via an ice screw and was on his way up the pitch using his front points and ice tools. Mark states that he did not notice significant pain or swelling at the time of the injury. She can be contacted at annecterry@hotmail. FW. He continued to climb that day and through the fall. In September of 2002. IN: Clinical Sports Medicine. She has been a member of the Seattle Mountaineers since 1994. wilderness medicine and women’s health. 2001. a triathlete and cyclist. It looks like a year after the incident his strength and mobility will be back to normal. One of the tears was also accompanied by an avulsion or chip fracture. Mark had surgery to repair the tears in March and is recovering nicely. Mark’s accident also confirms the importance of seeking care for an injury even if limitations seem minimal. Kharim. She is a first year intermediate climbing student.

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