Category Archive Fracture of Bone A-Z

Adult Forearm Fractures/The forearm is the part of the arm between the wrist and the elbow. It is made up of two bones: the radius and the ulna. Forearm fractures are common in childhood, accounting for more than 40% of all childhood fractures. About three out of four forearm fractures in children occur at the wrist end of the radius.

Forearm fractures often occur when children are playing on the playground or participating in sports. If a child takes a tumble and falls onto an outstretched arm, there is a chance it may result in a forearm fracture. A child’s bones heal more quickly than an adult’s, so it is important to treat a fracture promptly—before healing begins—to avoid future problems.

Adult Forearm Fractures – Types, Classifications

Colles’, Smith’s, Isolated Radial Shaft Fractures, Both Bone Fractures – The Colles’ fracture is the most common fracture of the distal radius in adults. It gets its name from Irish Surgeon, Dr. Abraham Colles, who first described this injury pattern in 1814. The mechanism of injury is classically a FOOSH. It is a metaphyseal fracture that occurs around 1.5 inches proximal to the carpal articulation. Characteristically it presents with dorsal angulation and displacement of the distal fragment of the radius. On X-Ray, the wrist will present with what is known as the “dinner-fork” deformity. Smith’s fracture is essentially the opposite of the Colles’ fracture. It is often referred to as a “reverse Colles’,” and occurs with a fall onto or a direct blow or force to the dorsum of the hand.

Chauffeur’s/Radial Styloid Fracture – The Chauffeur’s fracture is an intra-articular fracture of the radius that includes the radial styloid. The fracture fragment can be variable in size. The injury is often the result of a FOOSH injury with a blow to the back of the wrist causing dorsiflexion and abduction causing the scaphoid to compress against the radial styloid. Patients may have small avulsions of the radial styloid that are not clinically significant, but these injuries are often associated with disruption of the radioscaphocapitate and other collateral ligaments; this can lead to lunate dislocation and scapholunate disruption. These fractures were historically suffered by drivers who would need to start their cars using a hand crank. Occasionally these cranks would backfire and forcefully strike drivers on the back of the wrist.

Die-Punch Fracture – A die punch fracture is an intra-articular fracture involving the lunate facet of the radius. The lunate facet is one of the three articular surfaces of the distal radius. It lies between the ulnar articulation and the scaphoid facet. It connects the distal radius to the lunate bone in the wrist. A die-punch fracture occurs with axial loading of the lunate, which causes an impaction fracture to the lunate facet of the radius. This fracture often occurs in isolation but can have associated injuries.

Galeazzi Fracture-Dislocation – The Galeazzi fracture-dislocation is a fracture of the distal third of the radius with an associated distal radioulnar joint (DRUJ) dislocation. These fractures are typically the result of FOOSH injuries. It is an uncommon injury pattern, and the DRUJ component is easi to miss for clinicians. They are labeled based on the direction of ulnar displacement. For example, if the DRUJ disruption causes volar deviation of the ulna, this is classified as a “Volar Galeazzi.”

Barton’s Fracture – A Barton’s fracture is an intra-articular rim fracture of the distal radius. It can be classified as either dorsal or volar. Dorsal rim fractures are more common and result from forced dorsiflexion and pronation. Volar rim fractures often occur with a fall onto a supinated hand/wrist. These forces disrupt the radiocarpal ligaments and subsequent avulsion fracture of the radial rim. In dorsal fractures, the avulsed fragment migrates dorsally. The opposite is true with volar fractures. These fractures are unstable and often present with a dislocation of the carpal bones. [rx][rx]

Greenstick and Buckle/Torus Fractures – Both Torus and greenstick fractures are incomplete fractures. Pediatric bones are poorly mineralized relative to adults and can bend without frankly breaking. These fractures can occur in any long bone but frequently occur in the metaphysis of the distal radius. Torus fractures occur with axial loading whereas Greenstick fractures result from bending forces. Torus fractures are characterized by buckling of the bony cortex and periosteum without any true fracture lines. There is generally minimal deformity with Torus fractures, and the periosteum and cortex are intact. Greenstick fractures will show bony bending. There will be a fracture of the convex surface with an intact concave surface. These fractures are extremely common in children, and unfortunately frequently missed.

Salter-Harris Type Fractures – A Salter-Harris fracture is a pediatric fracture that involves the epiphyseal plate. These fractures can occur in any bone that has a growth plate but frequently occur in the distal radius. The Salter-Harris scheme was first developed by Doctors William Harris and Robert Salter in 1963 and remains the most common classification system for epiphyseal fractures. Salter-Harris fractures are graded I through IX, with I through V being the most frequently used in clinical practice. Type I is a fracture that runs transversely through the growth plate. Type II runs through the growth plate and the metaphysis. Type III involves the growth plate and epiphysis. Type IV is a fracture of metaphysis, epiphysis, and growth plate. Type V is a complete direct compression fracture of the growth plate. Each of these has a different prognosis and management. [rx][rx][rx]

Torus fracture – This is also called a buckle fracture. The topmost layer of bone on one side of the bone is compressed, causing the other side to bend away from the growth plate. This is a stable fracture, meaning that the broken pieces of bone are still in position and have not separated apart (displaced).

Metaphyseal fracture – The fracture is across the upper or lower portion of the shaft of the bone and does not affect the growth plate.

Growth plate fracture – Also called a physical fracture, this fracture occurs at or across the growth plate. In most cases, this type of fracture occurs in the growth plate of the radius near the wrist. Because the growth plate helps determine the future length and shape of the mature bone, this type of fracture requires prompt attention.

Differential Diagnosis

• Colles’ fracture
• Smith’s fracture
• Barton fracture
• Chauffeur’s fracture/radial styloid fracture
• Isolated distal radial fracture
• Both bone/radial and ulnar fracture
• Scaphoid/carpal bone fracture
• Scaphoid/carpal bone dislocation
• Distal radioulnar joint dislocation
• Carpal ligamentous disruption/TFCC injury
• Die-punch fracture
• Proximal metacarpal fracture
• Monteggia fracture
• Galeazzi fracture
• Greenstick fracture
• Torus/Buckle fracture
• Salter-Harris/growth plate fracture of radius (pediatric)

References

Galeazzi Fractures most commonly result from a fall onto an outstretched hand with an extended wrist and hyperpronated forearm. The energy from the radius fracture gets transmitted towards the radioulnar joint leading to dislocation of the DRUJ. These fractures occur with a bimodal distribution, diaphyseal forearm fractures in young males are commonly due to high-energy trauma (e.g., sports injuries, falls from height, motor vehicle collisions) and fractures in aging females are due to low-energy traumas such as falls from ground level.[rx][rx][rx]

Classification System of Galeazzi Fractures

Two classification systems have been proposed when categorizing Galeazzi fractures.

The first classifications were based on the position of the distal radius:

Type I: Dorsal displacement

Type II: Volar displacement

The second classification system is based on Rettig ME and Raskin KB who categorized Galeazzi fractures based on fracture stability. They found stability to be dependent on the distance of the radial fracture from the distal radial articular surface:

Type I:

• Fracture occurring distally from the 7.5 cm demarcation (i.e., closer to the wrist)
• Associated with significant DRUJ instability in more than 50% of cases

Type II:

• Fracture occurring proximally from the 7.5 cm demarcation (i.e., further from the wrist)
• Associated with significant DRUJ instability in only around 5% of cases

Causes of Galeazzi Fractures

• Sudden forceful  fall down
• Road traffic accident
• Falls – Falling onto an outstretched hand is one of the most common causes of a broken distal radius.
• Sports injuries – Many distal radius fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause wrist bones to break, sometimes into many pieces, and often require surgical repair.
• Have osteoporosis –  a disease that weakens your bones
• Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in the snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
• Wave an inadequate intake of calcium or vitamin D
• Football or soccer, especially on artificial turf
• Rugby
• Horseback riding
• Hockey
• Skiing
• Snowboarding
• In-line skating
• Jumping on a trampoline

Symptoms Of Galeazzi Fractures

Common symptoms of a distal radius fractures include:

• Severe pain that might worsen when gripping or squeezing or moving your hand or wrist
• Swelling
• Tenderness
• Bruising
• Obvious deformity, such as a bent wrist
• Pain
• Bruising
• Tenderness
• The wrist hanging in a deformed way
• Pain, especially when flexing the wrist
• Deformity of the wrist, causing it to look crooked and bent.
• Your wrist is in great pain.
• Your wrist, arm, or hand is numb.
• Your fingers are pale.

Diagnosis of Galeazzi Fractures

Imaging

If a forearm fracture and dislocation are suspected, radiographs are warranted. An anteroposterior and lateral view will usually identify the injury. An additional oblique view may help better classify the injury. Additional radiographs of the distal wrist and proximal elbow should be obtained with any suspicion of coexistent injury.

If a distal to mid-shaft radial fracture is seen on the radiograph, a close examination of the DRUJ is merited. Signs of DRUJ disruption include:

• Widening of the DRUJ on the PA view
• Ulnar styloid fracture
• Displacement of the ulna dorsally on the lateral view
• Radial shortening greater than 5 mm (would need to compare with unaffected limb)

Usually, advanced imaging is not needed for an initial assessment. For pre-operative planning, a CT scan may be used to evaluate for non-union, and magnetic resonance imaging (MRI) can help evaluate for TFCC tears and interosseous membrane disruption.

Treatment / Management of Galeazzi Fractures

All suspected or confirmed Galeazzi fractures will require orthopedist consultation. While awaiting consult, patients should be placed in a sugar-tong splint. In most cases, conservative management is indicated in children while surgical intervention is warranted in adults. Prior reports suggested treatment with closed reduction and immobilization alone, in adults, yielded poor outcomes in greater than 90% of patients.[rx][rx]

Initial Management

Initial management for a presumed fracture includes rest, ice, immobilization, and elevation. In most cases, closed reduction of the radius followed by a reduction of the ulna in the DRUJ should be attempted in the acute setting.

Pediatrics

Children tend to have overall better long-term outcomes compared to adults. The approach is usually conservative with closed reduction and splinting. Above-elbow casting in supination is the preferred immobilization. Irreducible and unstable injuries, as well as variants of the Galeazzi fracture, may require surgical intervention with open reduction and internal fixation (ORIF).

Non-Surgical

Treatment available can be broadly

Medication

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema
•  Antidepressants – A Drugs that block pain messages from your brain and boost the effects of endorphins (your body’s natural painkillers).
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include  and Ketorolac, Aceclofenac, naproxen
• Calcium & vitamin D3 – to improve bone health and healing fracture.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
• Corticosteroid- to healing the nerve inflammation and clotted blood in the joints.
• Dietary supplement -to remove general weakness & improved health.

References

Wrist Distal Radius Fracture/A distal radius fracture, commonly known as a wrist fracture, is defined by the involvement of the metaphysis of the distal radius. The fracture may or may not involve the radiocarpal joint, distal radioulnar joint, and/or the distal ulna.[rx] This injury is commonly associated with high-energy mechanisms in younger patients and lower energy mechanisms or falls in older patients.[rx] The fracture results in acute wrist pain and swelling, and if left untreated, it can result in significant morbidity. Treatment can involve both non-operative and operative management and ultimately depends on multiple factors.[rx]

Causes of Wrist Distal Radius Fracture

High-energy injuries may result in significantly displaced or highly comminuted unstable fractures to the distal radius.

Common mechanisms in younger individuals

• Falls from height
• Motor vehicle accident
• Injuries sustained during athletic participation
• Simple falls from standing height
• Sudden forceful  fall down
• Road traffic accident
• Falls – Falling onto an outstretched hand is one of the most common causes of a broken distal radius.
• Sports injuries – Many distal radius fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
• Motor vehicle crashes – Motor vehicle crashes can cause wrist bones to break, sometimes into many pieces, and often require surgical repair.
• Have osteoporosis –  a disease that weakens your bones
• Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
• Walk or do other activities in the snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
• Wave an inadequate intake of calcium or vitamin D
• Football or soccer, especially on artificial turf
• Rugby
• Horseback riding
• Hockey
• Skiing
• Snowboarding
• In-line skating
• Jumping on a trampoline

Symptoms of Wrist Distal Radius Fracture

• Swelling, pain, and stiffness in the wrist
• Clicking or clunking in the wrist
• The weakening of grip strength
• Tenderness directly over the lunate bone
• Difficulty or pain when turning the hand upward
• Wrist pain
• Tenderness directly over the lunate bone
• Decreased motion or stiffness of the wrist
• Swelling

Avascular Necrosis of the Lunate/Kienbock’s Disease, also known as avascular necrosis of the lunate, is a condition in which the lunate bone, one of eight small bones in the wrist, loses its blood supply, leading to the death of the bone. The lunate is a central bone in the wrist that is important for proper movement and support of the joint. It works closely with the two forearm bones (radius and ulna) to help the wrist move.

Kienbock disease refers to avascular necrosis of the lunate carpal bone, known as keratomalacia. It was first recognized and described by Austrian radiologist Robert Kienböck in 1910.[rx]

Causes of Kienbock’s Disease

No consensus is present regarding the primary causative factor of Kienböck disease. It is multifactorial, related to the following variables:

• Ulnar negative variance (or ulna minus) – This refers to a disproportionately shortened ulna when compared to the radius. As deduced from the previous section, a shortened ulna results in excessive mechanical stress and repetitive microtrauma exerted on the lunate by the relatively long radius. In some studies, up to 78% of Kienböck cases correlate with this finding.[rx]
• Vascular supply to the lunate bone – The lunate receives its blood supply from a variable number of dorsal and volar penetrating arteries that branch off of the dorsal and palmar radiocarpal and intercarpal arches. Intraosseous collaterals are sparse. The lower the number of penetrating arteries (especially volar branches from the radiocarpal palmar arch), the greater the likelihood of developing the disease.[rx][rx]
• Lunate morphology – The risk of developing Kienböck disease increases as lunate size decreases, forcing the lunate to carry a larger axial load. The lunate can either have a square/rectangular shape (type II or type III), or a more triangular shape whereby the medial articular facet is absent (type I). The latter has a weaker trabecular pattern and is a risk factor for disease development and progression.[rx]
• Radial inclination angle – the radial inclination angle is a measurement of the angle formed between the horizontal and a line drawn from the ulnar tip of the radial articular surface to the tip of the radial styloid. The risk of developing Kienböck disease increases as the radial inclination angle decreases.[rx]
• Skeletal variations – The ulna can be shorter than the radius, which may cause issues. Or, the shape of the lunate bone may be irregular.
• Trauma – A single incident or multiple incidents may cause this disease.
• Other medical conditions – Kienbock’s disease can be found more commonly in people who have medical conditions that affect blood supply, and it is also associated with diseases like lupus, sickle cell anemia and cerebral palsy.

Symptoms of Kienbock’s Disease/Avascular Necrosis of the Lunate

Common signs and symptoms are:

• Swelling, pain, and stiffness in the wrist
• Clicking or clunking in the wrist
• The weakening of grip strength
• Tenderness directly over the lunate bone
• Difficulty or pain when turning the hand upward
• Wrist pain
• Tenderness directly over the lunate bone
• Decreased motion or stiffness of the wrist
• Swelling

Diagnosis of Kienbock’s Disease/Avascular Necrosis of the Lunate

Kienböck disease is a clinical and imaging diagnosis. Both radiography/computed tomography and magnetic resonance imaging (MRI) is highly specific. However, MRI is the most sensitive and detects radiographically occult cases.

• Magnetic Resonance Imaging – Diffuse decrease in lunate bone marrow signal on T1-weighted images is a hallmark of the disease. Signal changes on T2-weighted images or short-TI inversion recovery (STIR, which nullifies signal from fat) images vary with progression and extent of osteonecrosis. MRI also assesses the integrity of the articular cartilage.[rx][rx]
• Radiography – Normal early in the disease. Findings, when present, depend on the morphological stage and include diffuse lunate sclerosis, cystic changes, articular surface collapse, carpal collapse, mid-carpal, and/or radio-carpal secondary arthrosis. Coronal fractures may occur in lunates with a type I morphology.[rx][rx]
• Computed Tomography – This is useful for surgical planning. It is also more sensitive than radiography for detecting subtle subchondral fractures, coronal lunate fractures, fragmentation, carpal instability, and the degree of trabecular disruption. Patients are frequently re-staged after CT imaging.[rx]
• Nuclear Scintigraphy – Findings are non-specific. It previously found use as an adjunct for diagnosing early-stage disease. It has fallen out of favor since introducing MRI.[rx]
• Ulnar impaction syndrome – More common with ulnar positive variance and results from repetitive microtrauma to the lunate from a relatively long ulna. Similar to Kienböck disease, ulnar impaction syndrome results in decreased T1-weighted signal coupled with increased T2 signal if hyperemia exists, or decreased T2 signal if the disease has already progressed to lunate sclerosis. The signal changes in Kienböck disease, however, are more diffuse or more severe on the radial side of the lunate. Additionally, ulnar impaction syndrome affects the ulnar head and triquetrum, which are intact in Kienböck patients.[rx][rx].
• Lunate intraosseous ganglion – Intraosseous ganglia are true cysts which have low T1 signal and high T2 signal on MRI. Sharp, smooth margins on both MRI and radiography allow distinction from Kienböck disease.[rx]
• Bone contusion – It May be difficult to distinguish early-stage Kienböck disease on MRI. A history of recent trauma and concomitant injuries to the wrist/hand, in this case, would aid in making the diagnosis.[rx]
• Arthritis – Bone marrow signal changes in inflammatory or degenerative arthritides may mimic those seen in Kienböck disease. Distinguishing features include demographics, clinical presentation, and absence of ulna minus in arthritis.[rx]
• Osteoid osteoma – Osteoid osteoma of the carpal bones is rare, and only a few case reports exist in the literature. Clinical presentation and the finding of a lucent nidus within a sclerotic rim on CT differentiate it from Kienböck disease.[rx]
• Enostosis/bone island – Has low signal intensity on all sequences, however, it shows preserved bone morphology and the area of “sclerosis”  is stellate and interdigitated with the normal trabeculae.[rx]

Prognosis of Avascular Necrosis of the Lunate

Kienbock disease is invariably progressive, and joint destruction occurs within 3-5 years of onset.[rx]

Prognosis depends on:

• Functional Staging – The greater the extent of viable bone, the better the prognosis.[rx]
• Negative ulnar variance – The greater the negative variance, the more severe the disease and the more likely it is to progress.[rx]
• Age at diagnosis – Patients diagnosed at an older age are more likely to have advanced-stage disease and are more likely to progress.[rx]

It is significant to note that the severity of symptoms does not always correlate with the morphologic stage.

References

Ulna/The ulna is a long bone found in the forearm that stretches from the elbow to the smallest finger, and when in anatomical position, is found on the medial side of the forearm. It runs parallel to the radius, the other long bone in the forearm, and is the bigger and longest (by about an inch) of the two.

Anatomy and Bone Landmarks of Ulna

Muscles Attachment of Ulna

The radius and ulna serve as insertion sites for several muscles originating more proximally in the arm[rx][rx]:

• Biceps brachii – inserts on the radial tuberosity, a bony prominence on the medial aspect of the proximal end of the radius; allows for flexion and supination of the forearm.
• Brachialis – inserts on the coronoid process of the ulna and the ulnar tuberosity; allows for flexion of the forearm.
• Triceps and anconeus – insert on the olecranon process of the ulna allowing for the extension of the forearm.

Within the forearm, muscles are classically grouped into anterior and posterior compartments[rx][rx]:

Anterior Compartment:

• Flexor carpi radialis, palmaris longus, and the humeral heads of the pronator teres and flexor carpi ulnaris – originate from the common flexor origin. The ulnar head of the pronator teres originates from the coronoid process. The ulnar head of the flexor carpi ulnaris arises from the olecranon. The pronator teres inserts to the lateral surface of the radius and is responsible for pronation and flexion of the forearm. Each of the other muscles inserts in the wrist or hand and is responsible for more distal movements.
• Flexor digitorum superficialis – arises from the anterior border of the radius, the medial epicondyle of the humerus, and the coronoid process and inserts on the middle phalanges of the medial four digits.
• Flexor digitorum profundus – arises from the ulna and interosseous membrane and inserts on the distal phalanges.
• Flexor pollicis longus – originates from the radius and the interosseous membrane and inserts on the distal phalanx of the thumb.
• Pronator quadratus – originates from the distal end of the ulna and inserts on the distal end of the radius.  Responsible for forearm pronation.

Posterior Compartment

• Brachioradialis, extensor carpi radialis longus, extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, and extensor carpi ulnaris – originate from the distal lateral edge of the humerus. The brachioradialis inserts just proximal to the styloid process of the radius and is responsible for flexion of the forearm, especially in pronation. The remainder of the muscles originating from this area insert distally and are responsible for movements within the wrist and hand.
• Supinator – originates from the lateral epicondyle, radial collateral and annular ligaments, supinator fossa and the crest of the ulna with insertion on the lateral side of the radius. It is responsible for forearm supination.
• Abductor pollicis longus and extensor pollicis longus – originates from the posterior surface of the ulna and interosseous membrane with attachments in the hand.
• Extensor indicis – originates from the posterior surface of the distal third of the ulna and the interosseous membrane with attachment in the hand.
• Extensor pollicis brevis – originates from the posterior surface of the distal third of the radius and the interosseous membrane with attachment in the hand.

The following muscles insert into the ulna

Triceps brachii – posterior section of the superior surface of the olecranonAnconeus – olecranonBrachialis – the volar surface of the coronoid process

The following muscles originate from the ulna[rx][rx]:

• Pronator teres – the medial surface of the coronoid process
• Flexor carpi ulnaris – olecranon process
• Flexor digitorum superficialis – coronoid process
• Flexor digitorum profundus – anteromedial surface
• Pronator quadratus – distal anterior shaft
• Extensor carpi ulnaris – posterior border
• Supinator – proximal ulna
• Abductor pollicis longus – posterior surface
• Extensor pollicis longus – dorsal shaft
• Extensor indicis – posterior distal shaft

Nerves of Ulna

The nerves of the brachial plexus provide motor and sensory innervation to the antebrachium.

The wrist joint receives innervation from the three major nerves of the forearm.[rx]

• Median nerve: Via the anterior interosseous branch
• Radial nerve: Via the posterior interosseous branch
• Ulnar nerve: Directly through its deep motor branches

The radial nerve provides sensory innervation for the posterior forearm and motor innervation to the brachioradialis, extensor carpi radialis brevis, extensor carpi radialis longus, supinator, extensor carpi ulnaris, abductor pollicis longus, abductor pollicis brevis, extensor pollicis longus, extensor pollicis brevis, extensor indicis, extensor digitorum, and extensor digiti minimi muscles.

The medial and lateral antebrachial cutaneous nerves provide sensory innervation to the anteromedial and anterolateral forearm respectfully.

The musculocutaneous nerve is the source of motor innervation to the biceps brachii.

The median nerve provides motor innervation to the pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, flexor pollicis longus, pronator quadratus, and the lateral half of the flexor digitorum profundus muscles.

The ulnar nerve supplies motor innervation to the flexor carpi ulnaris and flexor digitorum profundus muscles.[rx]

Functions of Ulna

Joints

The ulna forms part of the wrist joint and elbow joints. Specifically, the ulna joins (articulates) with:

• trochlea of the humerus, at the right side elbow as a hinge joint with the semilunar trochlear notch of the ulna.
• the radius, near the elbow as a pivot joint, allows the radius to cross over the ulna in pronation.
• the distal radius, where it fits into the ulnar notch.
• the radius along its length via the interosseous membrane that forms a syndesmosis joint

Musculotendinous Attachment of Ulna

Anteriorly

Proximal

• brachialis: ulnar tuberosity
• pronator teres (ulnar head): coronoid process
• flexor digitorum superficialis (humeroulnar head): coronoid process

Shaft

• flexor digitorum profundus: proximal anterior surface ulna
• pronator quadratus: anterior surface of the distal quarter of the ulnar shaft

Posteriorly

Proximal

• triceps brachii: proximal olecranon process
• anconeus: olecranon process

Shaft

• supinator: posterior proximal shaft of ulna
• flexor carpi ulnaris (ulnar head): medial border olecranon + posterior border of ulna
• extensor carpi ulnaris: posterior border of ulna
• abductor pollicis longus: posterior surface of ulna
• extensor pollicis longus: middle third of the posterior surface of ulna
• extensor indicis: posterior surface of ulna

Ligamentous

Proximal

• medial collateral ligaments of the elbow
  • • anterior band: inferior medial epicondyle to the sublime tubercle
    • posterior band: medial epicondyle to the medial olecranon
    • middle band (Transverse or Cooper’s ligament): medial olecranon to the medial coronoid process
• anterior and posterior capsular ligaments of the elbow.

Medial

• anterior and posterior attachments of the annular ligament
• quadrate ligament
• oblique cord
• interosseous membrane

Distal

• triangular fibrocartilage
• ulnar collateral ligament of the wrist

Clinical Significance of Ulna

Regardless of the site of the fracture, management should begin with a history and physical followed by plain films of the affected site, and if possible the joint above and below, orthogonal radiographic views of each site are mandatory to appropriately manage each fracture within the guidelines of the standard of care management. Common fractures include[rx]:

• Dorsally displaced distal radius fractures (commonly referred to as “Colle fractures”) – One of the most common forearm fractures. It involves a complete transverse fracture of the distal 2 cm of the radius.  The distal fragment is displaced posteriorly resulting in the classic “dinner fork” deformity.  The etiology is usually a fall on an outstretched hand with concomitant hyperextension. The fracture site can often be comminuted, and avulsion of the ulnar styloid process is also a feature.
• Reverse Colles fracture (Smith fracture) – A complete transverse fracture of the distal 2 cm of the radius with anterior displacement of the distal fragment. Usually secondary to a fall on a flexed hand.
• Monteggia fracture – A fracture within the proximal third of the ulna with concomitant dislocation of the radial head.[rx]
• Galeazzi’s fracture – A fracture of the distal third of the radius with accompanying dislocation of the distal radioulnar joint.
• Barton’s fracture – An intraarticular fracture of the distal radius with concomitant dislocation of the radiocarpal joint.[rx]
• Essex-Lopresti fracture-dislocation – Fracture of the radial head with dislocation of the distal radioulnar joint and rupture of the interosseous membrane.[rx]
• Chauffeur fracture – An intraarticular fracture of the radial styloid process.[rx]
• “Both Bone” forearm fractures – descriptive term to describe many different types of patterns involving fractures of the radius and ulnar shaft long bone

Incomplete fracture patterns of the forearm

• Isolated ulnar shaft fracture  -(greenstick fracture of the ulna)
• Isolated “buckle” or “torus” fracture pattern of the radius
• Seen in pediatric patients as a manifestation of a pathologic force compromising one cortex of the bone (resulting in compression on one side depending on the direction of the force).

References

Monteggia fractures most commonly result from a direct blow to the forearm with the elbow extended and forearm in hyperpronation. The energy from the ulnar fracture gets transmitted along the interosseous membrane leading to rupture of the proximal quadrate and annular ligaments, disrupting the radiocapitellar joint. In conjunction with the bimodal distribution, diaphyseal forearm fractures in young males are commonly due to high-energy trauma, for example, falls from height, sports injuries, motor vehicle accidents, and fractures in elderly females are due to low-energy trauma such as a ground-level fall.[rx][rx][rx]

Classification System of Monteggia Fractures

In 1967, Dr. Jose Luis Babo classified Monteggia fractures into four types. These types depend on the direction of the radial head dislocation.[rx]

Type I

• The proximal ulna is fractured and radial head dislocation directed anteriorly.
• Most common type in children accounting for 70% of cases, 15% of cases in adults.
• Mechanism of Injury: (1) direct blow to posterior elbow, (2) hyper-pronated force on an outstretched arm, (3) contracted biceps resists forearm extension causing dislocation and followed by impact leading to ulna fracture.

Type II

• Both the ulnar shaft fracture and radial head dislocation are directed posteriorly
• Mechanism of Injury: Axial load directed up the forearm with a slightly flexed elbow.
• Most common type in adults accounting for approximately 80% of cases.
• Associated with an instability of the ulnohumeral joint and high rates of radial head fracture and posterior interosseous nerve injury.

Type III

• Ulnar fracture with a radial head dislocation directed laterally.
• Mechanism of Injury: Varus force on an extended elbow leads to a greenstick fracture of the ulna.
• More frequently seen in children.

Type IV

• Fractures of the ulnar and radial shafts with an anterior radial head dislocation
• Rarest type and poorly understood mechanism.

Causes of Monteggia Fractures

Mechanisms include:

• Fall on an outstretched hand with the forearm in excessive pronation (hyper-pronation injury). The ulna fractures in the proximal one-third of the shaft due to extreme dislocation. Depending on the impact and forces applied in each direction, degree of energy absorption determines pattern, the involvement of the radial head, and whether or not open soft tissue occurs.
• Direct blow on the back of the upper forearm would be a very uncommon cause. In this context, isolated ulnar shaft fractures are most commonly seen in defense against blunt trauma (e.g. nightstick injury). Such an isolated ulnar shaft fracture is not a Monteggia fracture. It is called a ‘nightstick fracture’.

Diagnosis of Monteggia Fractures

Exam:
– r/o tear of the annular ligament
– associated nerve injury:
– paralysis of deep branch of the radial nerve is most common;
– the posterior interosseous nerve may be wrapped around the neck of radius, preventing reduction;
– note: that patients whose operative treatment is delayed may be found to have a progressive PIN palsy from
constant pressure exerted by the dislocated radial head;
– spontaneous recovery is usual & exploration is not indicated;

– Radiographs:
– dislocation of radial head may be missed, even though frx of the ulna is obvious (need AP, lateral and oblique X-rays of the elbow)
– a line is drawn thru radial shaft and radial head should align w/ capitalism in any position if the radial head is in normal position
– this is esp true on the lateral projection;
– the apex of angular deformity of ulna usually indicates the direction of radial head dislocation;

– Reduction:
– immobilize forearm in neutral rotation w/ slight supination, w/ cast carefully molded over the lateral side of the ulna at the level of fracture;
– keep elbow flexed ( > 90 deg), to relax biceps so that full supination can be avoided w/o losing reduction;

– Non-Operative Treatment:
– realize that even w/ successful closed reduction of the ulna (and accompanying reduction of the radial head) that subsequently
there may be slow and progressive shortening and angulation;
– hence, these patients will require close follow up;

Treatment of Monteggia Fractures

• Nonoperative
  • closed reduction 
    • indications
      • more common and successful in children
      • must ensure stabilty and anatomic alignment of ulna fracture
    • technique
      • cast in supination for Bado I and III
• Operative
  • ORIF of ulna shaft fracture
    • indications
      • acute fractures which are open or unstable (long oblique)
      • comminuted fractures
      • most Monteggia fractures in adults are treated surgically
  • ORIF of ulna shaft fracture, open reduction of radial head
    • indications
      • failure to reduce radial head with ORIF of ulnar shaft only
        • ensure ulnar reduction is correct
      • complex injury pattern
  • IM Nailing of ulna
    • indications
      • transverse or short oblique fracture

Delayed Dx:
– when dx is delayed < 3 months, ORIF is indicated;
– when > 3 months has elapsed, consider non-op treatment because bony ankylosis of the elbow may occur following surgery;
– bony ankylosis may be more disabling than the joint instability
– in a child, a dislocated radial head should never be resected, since it will cause cubitus valgus, prominence of the distal end of ulna,
and radial deviation of the head

Pearls and Pitfalls of Technique

• Missing pediatric – Monteggia leads to poor results. All “isolated ulna fractures” must be scrutinized for radio capitellar subluxation. Careful weekly radiographic follow-up, for the first 3 weeks after reduction is important to ensure the maintenance of reduction throughout treatment.
• Radiographic reading – Radiocapitellar line: The radial neck line should bisect the capitellar ossific nucleus.
• Ulnar bow sign: subtle bowing in the direction of the radial head dislocation. The posterior ulnar border should be straight.
• Most pediatric Monteggia fractures can be treated via closed means. Comminution, long oblique and very proximal ulna fractures have a higher risk of needing operative fixation.
• Residual radiocapitellar instability is almost always a result of residual ulnar deformity.
• Adult fractures often involve collateral ligament injury and radial head and coronoid fractures.
• The surgeon should be prepared to perform appropriate repairs and replacements.
• Osteoporosis must be taken into account when treating adult fractures.The threshold should be low for use of locking plate technology and for replacement instead of repair of the radial head.

References

Hamate fractures are rare and underreported. These injuries are usually misdiagnosed or confused with simple wrist sprains. Delayed diagnosis is not uncommon. The hamate is a triangular-shaped bone that forms part of the distal carpal row, articulating with the capitate (radially), triquetrum (proximally), and fifth and fourth metacarpals (distally).

Considering its unique anatomy (Figure 1), hamate fractures usually get subdivided into two broad groups: hook fractures and body fractures.[rx][rx]

Classification of hamate fractures:

• Type 1: Hook of the hamate fracture
• Type 2: Body of the hamate fracture

  • 2a: Coronal (may be dorsal oblique or splitting fracture)
  • 2b: Transverse fracture

Associated hook fracture injuries:

• Ulnar artery injury
• Ulnar nerve injury

Associated body fracture Injuries:

• Fourth and fifth metacarpal fracture-dislocation
• Greater arc perilunate fracture-dislocation

Differential Diagnosis

Ulnar flexor carpi tendinitis and triangular fibrocartilage complex injuries are a common misdiagnosis.[rx] A hamate fracture accompanies a small percentage (1 to 2%) of distal radius fracture.[rx]

Other differential diagnoses include:

• Bipartite hamate
• Scaphoid fracture
• Capitate fracture
• Triquetrum fracture
• Pisiform fracture
• Ligamentous injuries (without fracture)
• Carpal bone dislocations

Stiff Elbow (Elbow Contracture)/Elbow stiffness is a relatively common condition and represents a significant disability. There are multiple causes of loss of elbow range of motion. Therefore, a proper clinical history is important for therapeutic surgical or non-surgical planning.[rx]

Elbow Joints Injuries are the most common cause of elbow pain. Some people may not recall having had a specific injury, especially if symptoms began gradually or during everyday activities. To better understand elbow injuries, you may want to review the structure and function of the elbow.

Your elbow joint is made up of bone, cartilage, ligaments, and fluid. Muscles and tendons help the elbow joint move. When any of these structures is hurt or diseased, you have elbow problems. Many things can make your elbow hurt. A common cause is a tendinitis, an inflammation or injury to the tendons that attach muscle to bone. Tendinitis of the elbow is a sports injury, often from playing tennis or golf. You may also get tendinitis from the overuse of the elbow. Other causes of elbow pain include sprains and strains, fractures (broken bones), dislocations, bursitis, and arthritis. Treatment depends on the cause.

Types of Elbow Joints Fractures

Sudden (acute) injury

An acute injury may be caused by a direct blow, penetrating injury, or fall or by twisting, jerking, jamming, or bending an elbow abnormally. Pain may be sudden and severe. Bruising and swelling may develop soon after the injury. Acute injuries include:

• Bruises from a tear or rupture of small blood vessels under the skin.
• Injuries to ligaments, the ropy fibers that connect bones to bones around joints.
• Injuries to tendons that connect muscles to bones.
• Injuries to joints (sprains) that stretch or tear the ligaments.
• Pulled muscles (strains) caused by overstretching muscles.
• Muscle tears or ruptures, such as your biceps or triceps in your upper arm.
• Broken bones (fractures) of the upper arm bone (humerus) or the forearm bones (ulna or radius) at the elbow joint.
• Dislocations of the elbow joint (out of its normal position).

Overuse injuries

Overuse injuries occur when too much stress is placed on a joint or other tissue, often by overdoing an activity or through repetition of an activity. Overuse injuries include:

• Bursitis. Swelling behind the elbow may be olecranon bursitis (Popeye elbow).
• Tendinosis, which is a series of microtears in the connective tissue in or around the tendon.
  • Soreness or pain felt on the outside (lateral) part of the elbow may be tennis elbow (lateral epicondylitis). This is the most common type of tendinopathy that affects the elbow and most often is caused by overuse of the forearm muscles. This overuse may occur during sports, such as tennis, swimming, golf, and sports involving throwing; jobs, such as carpentry or plumbing; or daily activities, such as lifting objects or gardening.
  • Soreness or pain in the inner (medial) part of the elbow may be golfer’s elbow. In children who participate in sports that involve throwing, the same elbow pain may be described as Little Leaguer’s elbow.
• Pinched nerves, such as ulnar nerve compression, which is the pinching of the ulnar nerve near the elbow joint. This usually occurs with repeated motions.

Supracondylar Fractures

This type of fracture involves the distal humerus just above the elbow. It is the most common type of elbow fracture and accounts for approximately 60% of all elbow fractures. It is considered an injury of the immature skeleton and occurs in young children between 5 to 10 years of age. Based on the mechanism of injury and the displacement of the distal fragment, professionals classify these as either extension or flexion type fractures.[rx][rx][rx] Beware that a nondisplaced fracture may be subtle and may only be recognized by one of the following:

• Posterior fat pad sign
• Anterior sail sign
• Disruption of the anterior humeral line

Radiographically, these fractures are classified into three types:

• Type I –  minimal or no displacement
• Type II – displaced fracture, posterior cortex intact
• Type III –  totally displaced fracture, anterior and posterior cortices disrupted

In a flexion type fracture that happens in less than 5% of cases, the elbow is displaced anteriorly. The typical mechanism is when a direct anterior force is applied against a flexed elbow, which causes anterior displacement of the distal fragment. With the displacement of the fragment, the periosteum tears posteriorly. Since the mechanism is a direct force, flexion type fractures are often open.[rx][rx][rx][rx]

• Type I fracture – non-displaced or minimally displaced
• Type II fractures – incomplete fracture; anterior cortex is intact
• Type III fracture – completely displaced; distal fragment migrates proximally and anteriorly

One of the most serious complications is neurovascular injury following the fracture, as the brachial artery and median nerve are located close to the site of the fracture and can be easily compromised.

Gartland Classification

Supracondylar fractures can be classified depending on the degree of displacement:

• Gartland Type 1 Fracture – Minimally displaced or occult fracture. The fracture is difficult to see on x-rays. The anterior humeral line still intersects the anterior half of the capitellum. The only visible sign on an x-ray will be a positive fat pad sign.
• Gartland Type 2 Fracture – Fracture that is displaced more posteriorly, but the posterior cortex remains intact.
• Gartland Type 3 Fracture – Completely displaced fracture with cortical disruption. Posteromedial displacement is more common happening in 75% of cases compared to posterolateral displacement which occurs in 25% of cases.

Lateral Condyle Fractures

• These types of fractures are the second most common type of elbow fracture in children and account for 15% to 20% of all elbow fractures. This fracture involves the lateral condyle of the distal humerus, which is the outer bony prominence of the elbow.
• The peak age for the occurrence of lateral condyle fractures is four to ten years old. Most commonly, these are Salter-Harris type IV ( a fracture that transects the metaphysis, physis, and epiphysis) involving the lateral condyle.

Two types of classifications are used to describe lateral condyle fractures

Milch classification

• Milch 1 – Less common type. Fracture line traverses laterally to the trochlear groove. Elbow is stable.
• Milch II – More common type. Fracture passes through the trochlear groove. Elbow is unstable.

Displacement Classification

• Type 1 – Displacement of less than 2 mm
• Type 2 –  more than 2 mm but less than 4 mm displacement. The fragment is close to the humerus
• Type 3 – Wide displacement, the articular surface is disrupted.

Medial Epicondyle Fractures

• These fractures are the third most common type of elbow fracture in children. It is an extra-articular fracture. It involves a fracture of the medial epicondyle apophysis, which is located on the posteromedial aspect of the elbow.  It commonly occurs in early adolescence, between the ages of nine to 14 years of age.
• It is more common in boys and occurs during athletic activities such as football, baseball, or gymnastics. The common mechanisms of injury are a posterior elbow dislocation and repeated valgus stress. An example is throwing a baseball repeatedly. One term for this is “little league elbow.”

A common presentation is medial elbow pain, tenderness over the medial epicondyle, and valgus instability.

Radial Head and Neck Fractures

• These fractures comprise about 1% to 5% of all pediatric elbow fractures. Most commonly these are Salter-Harris type II fractures that transect the physis and extend into the metaphysis for a short distance. This usually occurs between the ages of nine to ten years.

Olecranon Fractures

• Olecranon fractures are uncommon in children. These are mostly associated with radial head and neck fractures.

Causes of Stiff Elbow (Elbow Contracture)

In general, elbow trauma can subdivide into the following categories:

Traumatic injuries

• Traumatic injuries range from simple contusions to more complex osseoligamentous fracture-dislocation patterns.  The latter is often seen following a fall on an outstretched hand while the forearm is supinated and the elbow is either partially flexed or fully extended

Attritional injuries

• Another form of elbow injuries consists of the subacute-to-chronic variety that occurs secondary to repetitive motions, eventually leading to various tendinosis conditions.  These can include but are not limited to, lateral epicondylitis (tennis elbow), and chronic partial UCL injuries or strains.[rx][rx]

Pediatric considerations

• Elbow trauma in children most commonly occurs via sport or following falls.  Moreover, careful attention during the assessment is necessary, given the characteristic sequence of ossification center appearance and fusion, which can make the radiographic assessment rather challenging.  Commonly encountered pediatric elbow fractures include (but are not limited to)[rx]

Another common elbow injury in children

• Subluxated radial head (nursemaid’s elbow)
• Accounts for 20% of all upper extremity injuries in children
• Peak age 1 to 4 years; occurs more frequently in females than males
• Mechanism of injury: sudden longitudinal pull on the forearm with forearm pronated

Signs and Symptoms of Stiff Elbow (Elbow Contracture)

Symptoms include:

• The child stops using the arm, which is held in extension (or slightly bent) and palm down.^[rx]
• Minimal swelling.
• All movements are permitted except supination.
• Pain on the outer part of the elbow (lateral epicondyle)
• Point tenderness over the lateral epicondyle—a prominent part of the bone on the outside of the elbow
• Pain from gripping and movements of the wrist, especially wrist extension (e.g. turning a screwdriver) and lifting movements^[rx]
• Sudden intense pain at the back of the elbow will be felt at the time of injury.
• The patient will in most cases be unable to straighten the elbow.
• Rapid swelling and bruising may start to appear. Trying to move the elbow will be painful and the back of the elbow will be very tender to touch.
• Caused by longitudinal traction with the wrist in pronation, although in a series only 51% of people were reported to have this mechanism, with 22% reporting falls, and patients less than 6 months of age noted to have the injury after rolling over in bed.
• Symptoms include pain and tenderness on the inside of the elbow. Bruising and swelling may be present for more severe injuries.
• Impact injuries causing damage to the medial ligament usually involves a lateral force (towards the outside) being applied to the forearm, placing the medial (inner) joint under stress.
• The patient presents with swelling over the lateral elbow with a limited range of motion, particularly forearm rotation and elbow extension ± elbow effusion and bruising. Pain is increased with passive rotation.
• The most reliable clinical sign is point tenderness over the radial head.
• Needs careful assessment for nerve and vascular involvement, especially with brachial artery, median and ulnar nerves.
• It is important to detect crepitation or a mechanical blockage of motion from displaced fracture fragments. This often requires aspiration of a haemarthrosis with the installation of local anesthetic for pain relief.
• If there is significant wrist pain and/or central forearm pain, there may be acute longitudinal radioulnar dissociation with disruption of the distal radioulnar joint.
• Overuse injuries of the MCL may also occur. Repetitive motions that place a lot of stress on the inner elbow can cause damage to the ligament. For example, throwers (track and field and ball sports such as baseball) are prone to this injury. Especially if the technique is poor!

Diagnosis of Stiff Elbow (Elbow Contracture)

Physical Examination

The examiner should perform and document relevant findings, including:

• Skin integrity

  • Critical when assessing for the presence of an open fracture and/or traumatic arthrotomy
• Presence of swelling or effusion
• Comprehensive neurovascular examination

How the patient carries their arm may give clues to the diagnosis.

Bony injuries

• Supracondylar fracture

  • Flexion type

    • Patient supports injured forearm with other arm and elbow in 90º flexion
    • Loss of olecranon prominence

  • Extension type

    • Patient hold arm at side in S-type configuration

Soft tissue injuries

• Elbow dislocations:

  • Posterior: abnormal prominence of olecranon
  • Anterior: loss of olecranon prominence

• Radial head subluxation

  • Elbow slightly flexed and forearm pronated resists moving the arm at the elbow

Sensory and motor testing of the Median and Ulnar nerves

Median

• Test for sensory function

  • Two-point discrimination over the tip of the index finger.

• Test for motor function

  • “OK” sign with thumb and index finger and abduction of the thumb (recurrent branch)

Ulnar

• Test for sensory function

  • Two-point discrimination of the little finger

• Test for motor function

  • Abduct index finger against resistance

Compartment Syndrome

Acute compartment syndrome can usually develop over a few hours after a serious injury. Some symptoms of acute compartment syndrome are:

• A new persistent deep pain
• Pain that seems greater than expected for the severity of the injury
• Numbness and tingling in the limb
• Swelling, tightness and bruising

Radiological Test

Radiographic studies that are necessary for all patients presenting with varying degrees of elbow trauma include:

• Anteroposterior (AP) elbow
• Lateral elbow
• Oblique views (optional, depending on fracture/injury)
• Traction view (optional, can facilitate the assessment of comminuted fracture patterns)

• Ipsilateral shoulder to wrist orthogonal views

  • Especially in the setting of high energy trauma or when exam and evaluation are limited

• Fat pad sign

  • Seen with intra-articular injuries
  • Normally, anterior fat pad is a narrow radiolucent strip anterior to humerus
  • The posterior fat pad is normally not visible
  • Anterior fat pad sign indicates joint effusion/ injury when raised and becomes more perpendicular to the anterior humeral cortex (sail sign)

  • Posterior fat pad sign indicates effusion/injury

    • In adults, posterior fat pad sign without other obvious fracture implies radial head fracture
    • In children, it implies supracondylar fracture

Pediatric Considerations

• Fractures in children often occur through unossified cartilage, making radiographic interpretation confusing
• A line of mensuration drawn down the anterior surface of the humerus should always bisect the capitellum in lateral view.
• If any bony relationship appears questionable on radiographs, obtain a comparison view of uninvolved elbow.
• Suspect nonaccidental trauma if history does not tip injury.

• Ossification centers: 1 appear: (CRITOE)

  • Capitellum 3 to 6 months
  • Radial head 3 to 5 years
  • Medial (Internal) epicondyle 5 to 7 years
  • Trochlea 9 to 10 years
  • Olecranon 9 to 10 years
  • Lateral Epicondyle

• It is essential to do bilateral radiographic imaging in pediatric cases.
• A nurse elbow can reduce spontaneously when the patient supinates the arm.

Advanced imaging sequences

Computerized tomography (CT) scans are often a consideration in the setting of comminuted fracture patterns for pre-operative surgical planning.  Magnetic resonance imaging (MRI) can be an option in the setting of soft tissue and ligamentous injury evaluation, or when suspecting stress or occult fractures.[rx][rx][rx]

Alert

Based on the complex anatomy of the elbow, a few things require attention:

• Neurovascular injuries to numerous structures that pass about the elbow, including anterior interosseous nerve, ulnar and radial nerves, brachial artery
• Volkmann ischemic contracture is compartment syndrome of the forearm

Differential Diagnosis

It is important to remember all possible diagnoses including (but not limited to):

• Fracture
• Dislocation
• Sprain
• Strain
• Ligamentous insufficiencies (e.g., UCL)
• Bursitis
• Tendinopathic conditions (acute or chronic)

Pediatric differential considerations include

• Child abuse

  • Distal humeral physeal injuries
• Nursemaids elbow
• Fracture(s)
• Avulsions
• Monteggia fracture-dislocations
• Physeal injuries/reactions

Treatment of Stiff Elbow (Elbow Contracture)

Doctors sometimes recommend very different treatments for both tennis elbow and golfer’s elbow. According to the studies done so far, the following treatments can help:

• Rest, ice
• Physical therapy when appropriate – Eccentric exercises for lateral epicondylitis
• Braces/bandages – These are worn around the elbow or on the forearm to take the strain off the muscles.
• Injections – Injections into the elbow with various substances, such as Botox, hyaluronic acid or autologous blood (the body’s own blood).
• Extracorporeal shockwave therapy (ESWT) – A device generates shock or pressure waves that are transferred to the tissue through the skin. This is supposed to improve the circulation of blood in the tissue and speed up the healing process.
• Laser therapy – The tissue is treated with concentrated beams of light. This is supposed to stimulate the circulation of blood and the body’s cell metabolism.
• Stretching and strengthening exercises: Special exercises that stretch and strengthen the muscles of the arm and wrist.
• Manual therapy – This includes active and passive exercises, as well as massages.
• Ultrasound therapy – The arm is exposed to high-frequency sound waves. This warms the tissue, which improves the circulation of blood.
• Transcutaneous electrical nerve stimulation (TENS) – TENS devices transfer electrical impulses to the nervous system through the skin. These are supposed to keep the pain signals from reaching the brain.
• Acupuncture – The acupuncture needles are inserted into certain points on the surface of the arm. Here, too, the aim is to minimize the perception of pain.
• Cold – The elbow is regularly cooled with ice packs.
• Massages –A massage technique called “transverse friction massage” is often used to treat tennis elbow and golfer’s elbow. It is applied to the tendons and the muscles, using the tips of one or two fingers.

Emergency department treatment and procedures

Elbow Joints Arthritis/The most common type of fracture in the pediatric population is elbow fractures. Most commonly,  individuals fall on their outstretched hand. Prompt assessment and management of elbow fractures are critical, as these fractures carry the risk of neurovascular compromise.

Elbow Joints Injuries are the most common cause of elbow pain. Some people may not recall having had a specific injury, especially if symptoms began gradually or during everyday activities. To better understand elbow injuries, you may want to review the structure and function of the elbow.

Your elbow joint is made up of bone, cartilage, ligaments, and fluid. Muscles and tendons help the elbow joint move. When any of these structures is hurt or diseased, you have elbow problems. Many things can make your elbow hurt. A common cause is a tendinitis, an inflammation or injury to the tendons that attach muscle to bone. Tendinitis of the elbow is a sports injury, often from playing tennis or golf. You may also get tendinitis from the overuse of the elbow. Other causes of elbow pain include sprains and strains, fractures (broken bones), dislocations, bursitis, and arthritis. Treatment depends on the cause.

Types of Elbow Joints Fractures

Sudden (acute) injury

An acute injury may be caused by a direct blow, penetrating injury, or fall or by twisting, jerking, jamming, or bending an elbow abnormally. Pain may be sudden and severe. Bruising and swelling may develop soon after the injury. Acute injuries include:

• Bruises from a tear or rupture of small blood vessels under the skin.
• Injuries to ligaments, the ropy fibers that connect bones to bones around joints.
• Injuries to tendons that connect muscles to bones.
• Injuries to joints (sprains) that stretch or tear the ligaments.
• Pulled muscles (strains) caused by overstretching muscles.
• Muscle tears or ruptures, such as your biceps or triceps in your upper arm.
• Broken bones (fractures) of the upper arm bone (humerus) or the forearm bones (ulna or radius) at the elbow joint.
• Dislocations of the elbow joint (out of its normal position).

Overuse injuries

Overuse injuries occur when too much stress is placed on a joint or other tissue, often by overdoing an activity or through repetition of an activity. Overuse injuries include:

• Bursitis. Swelling behind the elbow may be olecranon bursitis (Popeye elbow).
• Tendinosis, which is a series of microtears in the connective tissue in or around the tendon.
  • Soreness or pain felt on the outside (lateral) part of the elbow may be tennis elbow (lateral epicondylitis). This is the most common type of tendinopathy that affects the elbow and most often is caused by overuse of the forearm muscles. This overuse may occur during sports, such as tennis, swimming, golf, and sports involving throwing; jobs, such as carpentry or plumbing; or daily activities, such as lifting objects or gardening.
  • Soreness or pain in the inner (medial) part of the elbow may be golfer’s elbow. In children who participate in sports that involve throwing, the same elbow pain may be described as Little Leaguer’s elbow.
• Pinched nerves, such as ulnar nerve compression, which is the pinching of the ulnar nerve near the elbow joint. This usually occurs with repeated motions.

Supracondylar Fractures

This type of fracture involves the distal humerus just above the elbow. It is the most common type of elbow fracture and accounts for approximately 60% of all elbow fractures. It is considered an injury of the immature skeleton and occurs in young children between 5 to 10 years of age. Based on the mechanism of injury and the displacement of the distal fragment, professionals classify these as either extension or flexion type fractures.[rx][rx][rx] Beware that a nondisplaced fracture may be subtle and may only be recognized by one of the following:

• Posterior fat pad sign
• Anterior sail sign
• Disruption of the anterior humeral line

Radiographically, these fractures are classified into three types:

• Type I –  minimal or no displacement
• Type II – displaced fracture, posterior cortex intact
• Type III –  totally displaced fracture, anterior and posterior cortices disrupted

In a flexion type fracture that happens in less than 5% of cases, the elbow is displaced anteriorly. The typical mechanism is when a direct anterior force is applied against a flexed elbow, which causes anterior displacement of the distal fragment. With the displacement of the fragment, the periosteum tears posteriorly. Since the mechanism is a direct force, flexion type fractures are often open.[rx][rx][rx][rx]

• Type I fracture – non-displaced or minimally displaced
• Type II fractures – incomplete fracture; anterior cortex is intact
• Type III fracture – completely displaced; distal fragment migrates proximally and anteriorly

One of the most serious complications is neurovascular injury following the fracture, as the brachial artery and median nerve are located close to the site of the fracture and can be easily compromised.

Gartland Classification

Supracondylar fractures can be classified depending on the degree of displacement:

• Gartland Type 1 Fracture – Minimally displaced or occult fracture. The fracture is difficult to see on x-rays. The anterior humeral line still intersects the anterior half of the capitellum. The only visible sign on an x-ray will be a positive fat pad sign.
• Gartland Type 2 Fracture – Fracture that is displaced more posteriorly, but the posterior cortex remains intact.
• Gartland Type 3 Fracture – Completely displaced fracture with cortical disruption. Posteromedial displacement is more common happening in 75% of cases compared to posterolateral displacement which occurs in 25% of cases.

Lateral Condyle Fractures

• These types of fractures are the second most common type of elbow fracture in children and account for 15% to 20% of all elbow fractures. This fracture involves the lateral condyle of the distal humerus, which is the outer bony prominence of the elbow.
• The peak age for the occurrence of lateral condyle fractures is four to ten years old. Most commonly, these are Salter-Harris type IV ( a fracture that transects the metaphysis, physis, and epiphysis) involving the lateral condyle.

Two types of classifications are used to describe lateral condyle fractures

Milch classification

• Milch 1 – Less common type. Fracture line traverses laterally to the trochlear groove. Elbow is stable.
• Milch II – More common type. Fracture passes through the trochlear groove. Elbow is unstable.

Displacement Classification

• Type 1 – Displacement of less than 2 mm
• Type 2 –  more than 2 mm but less than 4 mm displacement. The fragment is close to the humerus
• Type 3 – Wide displacement, the articular surface is disrupted.

Medial Epicondyle Fractures

• These fractures are the third most common type of elbow fracture in children. It is an extra-articular fracture. It involves a fracture of the medial epicondyle apophysis, which is located on the posteromedial aspect of the elbow.  It commonly occurs in early adolescence, between the ages of nine to 14 years of age.
• It is more common in boys and occurs during athletic activities such as football, baseball, or gymnastics. The common mechanisms of injury are a posterior elbow dislocation and repeated valgus stress. An example is throwing a baseball repeatedly. One term for this is “little league elbow.”

A common presentation is medial elbow pain, tenderness over the medial epicondyle, and valgus instability.

Radial Head and Neck Fractures

• These fractures comprise about 1% to 5% of all pediatric elbow fractures. Most commonly these are Salter-Harris type II fractures that transect the physis and extend into the metaphysis for a short distance. This usually occurs between the ages of nine to ten years.

Olecranon Fractures

• Olecranon fractures are uncommon in children. These are mostly associated with radial head and neck fractures.

Causes of Elbow Joints Arthritis

In general, elbow trauma can subdivide into the following categories:

Traumatic injuries

• Traumatic injuries range from simple contusions to more complex osseoligamentous fracture-dislocation patterns.  The latter is often seen following a fall on an outstretched hand while the forearm is supinated and the elbow is either partially flexed or fully extended

Attritional injuries

• Another form of elbow injuries consists of the subacute-to-chronic variety that occurs secondary to repetitive motions, eventually leading to various tendinosis conditions.  These can include but are not limited to, lateral epicondylitis (tennis elbow), and chronic partial UCL injuries or strains.[rx][rx]

Pediatric considerations

• Elbow trauma in children most commonly occurs via sport or following falls.  Moreover, careful attention during the assessment is necessary, given the characteristic sequence of ossification center appearance and fusion, which can make the radiographic assessment rather challenging.  Commonly encountered pediatric elbow fractures include (but are not limited to)[rx]

Another common elbow injury in children

• Subluxated radial head (nursemaid’s elbow)
• Accounts for 20% of all upper extremity injuries in children
• Peak age 1 to 4 years; occurs more frequently in females than males
• Mechanism of injury: sudden longitudinal pull on the forearm with forearm pronated

Signs and Symptoms of Elbow Joints Arthritis

Symptoms include:

• The child stops using the arm, which is held in extension (or slightly bent) and palm down.^[rx]
• Minimal swelling.
• All movements are permitted except supination.
• Pain on the outer part of the elbow (lateral epicondyle)
• Point tenderness over the lateral epicondyle—a prominent part of the bone on the outside of the elbow
• Pain from gripping and movements of the wrist, especially wrist extension (e.g. turning a screwdriver) and lifting movements^[rx]
• Sudden intense pain at the back of the elbow will be felt at the time of injury.
• The patient will in most cases be unable to straighten the elbow.
• Rapid swelling and bruising may start to appear. Trying to move the elbow will be painful and the back of the elbow will be very tender to touch.
• Caused by longitudinal traction with the wrist in pronation, although in a series only 51% of people were reported to have this mechanism, with 22% reporting falls, and patients less than 6 months of age noted to have the injury after rolling over in bed.
• Symptoms include pain and tenderness on the inside of the elbow. Bruising and swelling may be present for more severe injuries.
• Impact injuries causing damage to the medial ligament usually involves a lateral force (towards the outside) being applied to the forearm, placing the medial (inner) joint under stress.
• The patient presents with swelling over the lateral elbow with a limited range of motion, particularly forearm rotation and elbow extension ± elbow effusion and bruising. Pain is increased with passive rotation.
• The most reliable clinical sign is point tenderness over the radial head.
• Needs careful assessment for nerve and vascular involvement, especially with brachial artery, median and ulnar nerves.
• It is important to detect crepitation or a mechanical blockage of motion from displaced fracture fragments. This often requires aspiration of a haemarthrosis with the installation of local anesthetic for pain relief.
• If there is significant wrist pain and/or central forearm pain, there may be acute longitudinal radioulnar dissociation with disruption of the distal radioulnar joint.
• Overuse injuries of the MCL may also occur. Repetitive motions that place a lot of stress on the inner elbow can cause damage to the ligament. For example, throwers (track and field and ball sports such as baseball) are prone to this injury. Especially if the technique is poor!

Diagnosis of Elbow Joints Arthritis

Physical Examination

The examiner should perform and document relevant findings, including:

• Skin integrity

  • Critical when assessing for the presence of an open fracture and/or traumatic arthrotomy
• Presence of swelling or effusion
• Comprehensive neurovascular examination

How the patient carries their arm may give clues to the diagnosis.

Bony injuries

• Supracondylar fracture

  • Flexion type

    • Patient supports injured forearm with other arm and elbow in 90º flexion
    • Loss of olecranon prominence

  • Extension type

    • Patient hold arm at side in S-type configuration

Soft tissue injuries

• Elbow dislocations:

  • Posterior: abnormal prominence of olecranon
  • Anterior: loss of olecranon prominence

• Radial head subluxation

  • Elbow slightly flexed and forearm pronated resists moving the arm at the elbow

Sensory and motor testing of the Median and Ulnar nerves

Median

• Test for sensory function

  • Two-point discrimination over the tip of the index finger.

• Test for motor function

  • “OK” sign with thumb and index finger and abduction of the thumb (recurrent branch)

Ulnar

• Test for sensory function

  • Two-point discrimination of the little finger

• Test for motor function

  • Abduct index finger against resistance

Compartment Syndrome

Acute compartment syndrome can usually develop over a few hours after a serious injury. Some symptoms of acute compartment syndrome are:

• A new persistent deep pain
• Pain that seems greater than expected for the severity of the injury
• Numbness and tingling in the limb
• Swelling, tightness and bruising

Radiological Test

Radiographic studies that are necessary for all patients presenting with varying degrees of elbow trauma include:

• Anteroposterior (AP) elbow
• Lateral elbow
• Oblique views (optional, depending on fracture/injury)
• Traction view (optional, can facilitate the assessment of comminuted fracture patterns)

• Ipsilateral shoulder to wrist orthogonal views

  • Especially in the setting of high energy trauma or when exam and evaluation are limited

• Fat pad sign

  • Seen with intra-articular injuries
  • Normally, anterior fat pad is a narrow radiolucent strip anterior to humerus
  • The posterior fat pad is normally not visible
  • Anterior fat pad sign indicates joint effusion/ injury when raised and becomes more perpendicular to the anterior humeral cortex (sail sign)

  • Posterior fat pad sign indicates effusion/injury

    • In adults, posterior fat pad sign without other obvious fracture implies radial head fracture
    • In children, it implies supracondylar fracture

Pediatric Considerations

• Fractures in children often occur through unossified cartilage, making radiographic interpretation confusing
• A line of mensuration drawn down the anterior surface of the humerus should always bisect the capitellum in lateral view.
• If any bony relationship appears questionable on radiographs, obtain a comparison view of uninvolved elbow.
• Suspect nonaccidental trauma if history does not tip injury.

• Ossification centers: 1 appear: (CRITOE)

  • Capitellum 3 to 6 months
  • Radial head 3 to 5 years
  • Medial (Internal) epicondyle 5 to 7 years
  • Trochlea 9 to 10 years
  • Olecranon 9 to 10 years
  • Lateral Epicondyle

• It is essential to do bilateral radiographic imaging in pediatric cases.
• A nurse elbow can reduce spontaneously when the patient supinates the arm.

Advanced imaging sequences

Computerized tomography (CT) scans are often a consideration in the setting of comminuted fracture patterns for pre-operative surgical planning.  Magnetic resonance imaging (MRI) can be an option in the setting of soft tissue and ligamentous injury evaluation, or when suspecting stress or occult fractures.[rx][rx][rx]

Alert

Based on the complex anatomy of the elbow, a few things require attention:

• Neurovascular injuries to numerous structures that pass about the elbow, including anterior interosseous nerve, ulnar and radial nerves, brachial artery
• Volkmann ischemic contracture is compartment syndrome of the forearm

Differential Diagnosis

It is important to remember all possible diagnoses including (but not limited to):

• Fracture
• Dislocation
• Sprain
• Strain
• Ligamentous insufficiencies (e.g., UCL)
• Bursitis
• Tendinopathic conditions (acute or chronic)

Pediatric differential considerations include

• Child abuse

  • Distal humeral physeal injuries
• Nursemaids elbow
• Fracture(s)
• Avulsions
• Monteggia fracture-dislocations
• Physeal injuries/reactions

Treatment of Elbow Joints Arthritis

Doctors sometimes recommend very different treatments for both tennis elbow and golfer’s elbow. According to the studies done so far, the following treatments can help:

• Rest, ice
• Physical therapy when appropriate – Eccentric exercises for lateral epicondylitis
• Braces/bandages – These are worn around the elbow or on the forearm to take the strain off the muscles.
• Injections – Injections into the elbow with various substances, such as Botox, hyaluronic acid or autologous blood (the body’s own blood).
• Extracorporeal shockwave therapy (ESWT) – A device generates shock or pressure waves that are transferred to the tissue through the skin. This is supposed to improve the circulation of blood in the tissue and speed up the healing process.
• Laser therapy – The tissue is treated with concentrated beams of light. This is supposed to stimulate the circulation of blood and the body’s cell metabolism.
• Stretching and strengthening exercises: Special exercises that stretch and strengthen the muscles of the arm and wrist.
• Manual therapy – This includes active and passive exercises, as well as massages.
• Ultrasound therapy – The arm is exposed to high-frequency sound waves. This warms the tissue, which improves the circulation of blood.
• Transcutaneous electrical nerve stimulation (TENS) – TENS devices transfer electrical impulses to the nervous system through the skin. These are supposed to keep the pain signals from reaching the brain.
• Acupuncture – The acupuncture needles are inserted into certain points on the surface of the arm. Here, too, the aim is to minimize the perception of pain.
• Cold – The elbow is regularly cooled with ice packs.
• Massages –A massage technique called “transverse friction massage” is often used to treat tennis elbow and golfer’s elbow. It is applied to the tendons and the muscles, using the tips of one or two fingers.

Emergency department treatment and procedures

Elbow Joints Fractures/The most common type of fracture in the pediatric population is elbow fractures. Most commonly,  individuals fall on their outstretched hand. Prompt assessment and management of elbow fractures are critical, as these fractures carry the risk of neurovascular compromise.

Elbow Joints Injuries are the most common cause of elbow pain. Some people may not recall having had a specific injury, especially if symptoms began gradually or during everyday activities. To better understand elbow injuries, you may want to review the structure and function of the elbow. See a picture of the elbow.

Your elbow joint is made up of bone, cartilage, ligaments, and fluid. Muscles and tendons help the elbow joint move. When any of these structures is hurt or diseased, you have elbow problems. Many things can make your elbow hurt. A common cause is a tendinitis, an inflammation or injury to the tendons that attach muscle to bone. Tendinitis of the elbow is a sports injury, often from playing tennis or golf. You may also get tendinitis from the overuse of the elbow. Other causes of elbow pain include sprains and strains, fractures (broken bones), dislocations, bursitis, and arthritis. Treatment depends on the cause.

Types of Elbow Joints Fractures

Sudden (acute) injury

An acute injury may be caused by a direct blow, penetrating injury, or fall or by twisting, jerking, jamming, or bending an elbow abnormally. Pain may be sudden and severe. Bruising and swelling may develop soon after the injury. Acute injuries include:

• Bruises from a tear or rupture of small blood vessels under the skin.
• Injuries to ligaments, the ropy fibers that connect bones to bones around joints.
• Injuries to tendons that connect muscles to bones.
• Injuries to joints (sprains) that stretch or tear the ligaments.
• Pulled muscles (strains) caused by overstretching muscles.
• Muscle tears or ruptures, such as your biceps or triceps in your upper arm.
• Broken bones (fractures) of the upper arm bone (humerus) or the forearm bones (ulna or radius) at the elbow joint.
• Dislocations of the elbow joint (out of its normal position).

Overuse injuries

Overuse injuries occur when too much stress is placed on a joint or other tissue, often by overdoing an activity or through repetition of an activity. Overuse injuries include:

• Bursitis. Swelling behind the elbow may be olecranon bursitis (Popeye elbow).
• Tendinosis, which is a series of microtears in the connective tissue in or around the tendon.
  • Soreness or pain felt on the outside (lateral) part of the elbow may be tennis elbow (lateral epicondylitis). This is the most common type of tendinopathy that affects the elbow and most often is caused by overuse of the forearm muscles. This overuse may occur during sports, such as tennis, swimming, golf, and sports involving throwing; jobs, such as carpentry or plumbing; or daily activities, such as lifting objects or gardening.
  • Soreness or pain in the inner (medial) part of the elbow may be golfer’s elbow. In children who participate in sports that involve throwing, the same elbow pain may be described as Little Leaguer’s elbow.
• Pinched nerves, such as ulnar nerve compression, which is the pinching of the ulnar nerve near the elbow joint. This usually occurs with repeated motions.

Supracondylar Fractures

This type of fracture involves the distal humerus just above the elbow. It is the most common type of elbow fracture and accounts for approximately 60% of all elbow fractures. It is considered an injury of the immature skeleton and occurs in young children between 5 to 10 years of age. Based on the mechanism of injury and the displacement of the distal fragment, professionals classify these as either extension or flexion type fractures.[rx][rx][rx] Beware that a nondisplaced fracture may be subtle and may only be recognized by one of the following:

• Posterior fat pad sign
• Anterior sail sign
• Disruption of the anterior humeral line

Radiographically, these fractures are classified into three types:

• Type I –  minimal or no displacement
• Type II – displaced fracture, posterior cortex intact
• Type III –  totally displaced fracture, anterior and posterior cortices disrupted

In a flexion type fracture that happens in less than 5% of cases, the elbow is displaced anteriorly. The typical mechanism is when a direct anterior force is applied against a flexed elbow, which causes anterior displacement of the distal fragment. With the displacement of the fragment, the periosteum tears posteriorly. Since the mechanism is a direct force, flexion type fractures are often open.[rx][rx][rx][rx]

• Type I fracture – non-displaced or minimally displaced
• Type II fractures – incomplete fracture; anterior cortex is intact
• Type III fracture – completely displaced; distal fragment migrates proximally and anteriorly

One of the most serious complications is neurovascular injury following the fracture, as the brachial artery and median nerve are located close to the site of the fracture and can be easily compromised.

Gartland Classification

Supracondylar fractures can be classified depending on the degree of displacement:

• Gartland Type 1 Fracture – Minimally displaced or occult fracture. The fracture is difficult to see on x-rays. The anterior humeral line still intersects the anterior half of the capitellum. The only visible sign on an x-ray will be a positive fat pad sign.
• Gartland Type 2 Fracture – Fracture that is displaced more posteriorly, but the posterior cortex remains intact.
• Gartland Type 3 Fracture – Completely displaced fracture with cortical disruption. Posteromedial displacement is more common happening in 75% of cases compared to posterolateral displacement which occurs in 25% of cases.

Lateral Condyle Fractures

• These types of fractures are the second most common type of elbow fracture in children and account for 15% to 20% of all elbow fractures. This fracture involves the lateral condyle of the distal humerus, which is the outer bony prominence of the elbow.
• The peak age for the occurrence of lateral condyle fractures is four to ten years old. Most commonly, these are Salter-Harris type IV ( a fracture that transects the metaphysis, physis, and epiphysis) involving the lateral condyle.

Two types of classifications are used to describe lateral condyle fractures

Milch classification

• Milch 1 – Less common type. Fracture line traverses laterally to the trochlear groove. Elbow is stable.
• Milch II – More common type. Fracture passes through the trochlear groove. Elbow is unstable.

Displacement Classification

• Type 1 – Displacement of less than 2 mm
• Type 2 –  more than 2 mm but less than 4 mm displacement. The fragment is close to the humerus
• Type 3 – Wide displacement, the articular surface is disrupted.

Medial Epicondyle Fractures

• These fractures are the third most common type of elbow fracture in children. It is an extra-articular fracture. It involves a fracture of the medial epicondyle apophysis, which is located on the posteromedial aspect of the elbow.  It commonly occurs in early adolescence, between the ages of nine to 14 years of age.
• It is more common in boys and occurs during athletic activities such as football, baseball, or gymnastics. The common mechanisms of injury are a posterior elbow dislocation and repeated valgus stress. An example is throwing a baseball repeatedly. One term for this is “little league elbow.”

A common presentation is medial elbow pain, tenderness over the medial epicondyle, and valgus instability.

Radial Head and Neck Fractures

• These fractures comprise about 1% to 5% of all pediatric elbow fractures. Most commonly these are Salter-Harris type II fractures that transect the physis and extend into the metaphysis for a short distance. This usually occurs between the ages of nine to ten years.

Olecranon Fractures

• Olecranon fractures are uncommon in children. These are mostly associated with radial head and neck fractures.

Causes of Elbow Joints Fractures

In general, elbow trauma can subdivide into the following categories:

Traumatic injuries

• Traumatic injuries range from simple contusions to more complex osseoligamentous fracture-dislocation patterns.  The latter is often seen following a fall on an outstretched hand while the forearm is supinated and the elbow is either partially flexed or fully extended

Attritional injuries

• Another form of elbow injuries consists of the subacute-to-chronic variety that occurs secondary to repetitive motions, eventually leading to various tendinosis conditions.  These can include but are not limited to, lateral epicondylitis (tennis elbow), and chronic partial UCL injuries or strains.[rx][rx]

Pediatric considerations

• Elbow trauma in children most commonly occurs via sport or following falls.  Moreover, careful attention during the assessment is necessary, given the characteristic sequence of ossification center appearance and fusion, which can make the radiographic assessment rather challenging.  Commonly encountered pediatric elbow fractures include (but are not limited to)[rx]

Another common elbow injury in children

• Subluxated radial head (nursemaid’s elbow)
• Accounts for 20% of all upper extremity injuries in children
• Peak age 1 to 4 years; occurs more frequently in females than males
• Mechanism of injury: sudden longitudinal pull on the forearm with forearm pronated

Signs and Symptoms of Elbow Joints Fractures

Symptoms include:

• The child stops using the arm, which is held in extension (or slightly bent) and palm down.^[rx]
• Minimal swelling.
• All movements are permitted except supination.
• Pain on the outer part of the elbow (lateral epicondyle)
• Point tenderness over the lateral epicondyle—a prominent part of the bone on the outside of the elbow
• Pain from gripping and movements of the wrist, especially wrist extension (e.g. turning a screwdriver) and lifting movements^[rx]
• Sudden intense pain at the back of the elbow will be felt at the time of injury.
• The patient will in most cases be unable to straighten the elbow.
• Rapid swelling and bruising may start to appear. Trying to move the elbow will be painful and the back of the elbow will be very tender to touch.
• Caused by longitudinal traction with the wrist in pronation, although in a series only 51% of people were reported to have this mechanism, with 22% reporting falls, and patients less than 6 months of age noted to have the injury after rolling over in bed.
• Symptoms include pain and tenderness on the inside of the elbow. Bruising and swelling may be present for more severe injuries.
• Impact injuries causing damage to the medial ligament usually involves a lateral force (towards the outside) being applied to the forearm, placing the medial (inner) joint under stress.
• The patient presents with swelling over the lateral elbow with a limited range of motion, particularly forearm rotation and elbow extension ± elbow effusion and bruising. Pain is increased with passive rotation.
• The most reliable clinical sign is point tenderness over the radial head.
• Needs careful assessment for nerve and vascular involvement, especially with brachial artery, median and ulnar nerves.
• It is important to detect crepitation or a mechanical blockage of motion from displaced fracture fragments. This often requires aspiration of a haemarthrosis with the installation of local anesthetic for pain relief.
• If there is significant wrist pain and/or central forearm pain, there may be acute longitudinal radioulnar dissociation with disruption of the distal radioulnar joint.
• Overuse injuries of the MCL may also occur. Repetitive motions that place a lot of stress on the inner elbow can cause damage to the ligament. For example, throwers (track and field and ball sports such as baseball) are prone to this injury. Especially if the technique is poor!

Diagnosis of Elbow Joints Fractures

Physical Examination

The examiner should perform and document relevant findings, including:

• Skin integrity

  • Critical when assessing for the presence of an open fracture and/or traumatic arthrotomy
• Presence of swelling or effusion
• Comprehensive neurovascular examination

How the patient carries their arm may give clues to the diagnosis.

Bony injuries

• Supracondylar fracture

  • Flexion type

    • Patient supports injured forearm with other arm and elbow in 90º flexion
    • Loss of olecranon prominence

  • Extension type

    • Patient hold arm at side in S-type configuration

Soft tissue injuries

• Elbow dislocations:

  • Posterior: abnormal prominence of olecranon
  • Anterior: loss of olecranon prominence

• Radial head subluxation

  • Elbow slightly flexed and forearm pronated resists moving the arm at the elbow

Sensory and motor testing of the Median and Ulnar nerves

Median

• Test for sensory function

  • Two-point discrimination over the tip of the index finger.

• Test for motor function

  • “OK” sign with thumb and index finger and abduction of the thumb (recurrent branch)

Ulnar

• Test for sensory function

  • Two-point discrimination of the little finger

• Test for motor function

  • Abduct index finger against resistance

Compartment Syndrome

Acute compartment syndrome can usually develop over a few hours after a serious injury. Some symptoms of acute compartment syndrome are:

• A new persistent deep pain
• Pain that seems greater than expected for the severity of the injury
• Numbness and tingling in the limb
• Swelling, tightness and bruising

Radiological Test

Radiographic studies that are necessary for all patients presenting with varying degrees of elbow trauma include:

• Anteroposterior (AP) elbow
• Lateral elbow
• Oblique views (optional, depending on fracture/injury)
• Traction view (optional, can facilitate the assessment of comminuted fracture patterns)

• Ipsilateral shoulder to wrist orthogonal views

  • Especially in the setting of high energy trauma or when exam and evaluation are limited

• Fat pad sign

  • Seen with intra-articular injuries
  • Normally, anterior fat pad is a narrow radiolucent strip anterior to humerus
  • The posterior fat pad is normally not visible
  • Anterior fat pad sign indicates joint effusion/ injury when raised and becomes more perpendicular to the anterior humeral cortex (sail sign)

  • Posterior fat pad sign indicates effusion/injury

    • In adults, posterior fat pad sign without other obvious fracture implies radial head fracture
    • In children, it implies supracondylar fracture

Pediatric Considerations

• Fractures in children often occur through unossified cartilage, making radiographic interpretation confusing
• A line of mensuration drawn down the anterior surface of the humerus should always bisect the capitellum in lateral view.
• If any bony relationship appears questionable on radiographs, obtain a comparison view of uninvolved elbow.
• Suspect nonaccidental trauma if history does not tip injury.

• Ossification centers: 1 appear: (CRITOE)

  • Capitellum 3 to 6 months
  • Radial head 3 to 5 years
  • Medial (Internal) epicondyle 5 to 7 years
  • Trochlea 9 to 10 years
  • Olecranon 9 to 10 years
  • Lateral Epicondyle

• It is essential to do bilateral radiographic imaging in pediatric cases.
• A nurse elbow can reduce spontaneously when the patient supinates the arm.

Advanced imaging sequences

Computerized tomography (CT) scans are often a consideration in the setting of comminuted fracture patterns for pre-operative surgical planning.  Magnetic resonance imaging (MRI) can be an option in the setting of soft tissue and ligamentous injury evaluation, or when suspecting stress or occult fractures.[rx][rx][rx]

Alert

Based on the complex anatomy of the elbow, a few things require attention:

• Neurovascular injuries to numerous structures that pass about the elbow, including anterior interosseous nerve, ulnar and radial nerves, brachial artery
• Volkmann ischemic contracture is compartment syndrome of the forearm

Differential Diagnosis

It is important to remember all possible diagnoses including (but not limited to):

• Fracture
• Dislocation
• Sprain
• Strain
• Ligamentous insufficiencies (e.g., UCL)
• Bursitis
• Tendinopathic conditions (acute or chronic)

Pediatric differential considerations include

• Child abuse

  • Distal humeral physeal injuries
• Nursemaids elbow
• Fracture(s)
• Avulsions
• Monteggia fracture-dislocations
• Physeal injuries/reactions

Treatment of Elbow Joints Fractures

Doctors sometimes recommend very different treatments for both tennis elbow and golfer’s elbow. According to the studies done so far, the following treatments can help:

• Rest, ice
• Physical therapy when appropriate – Eccentric exercises for lateral epicondylitis
• Braces/bandages – These are worn around the elbow or on the forearm to take the strain off the muscles.
• Injections – Injections into the elbow with various substances, such as Botox, hyaluronic acid or autologous blood (the body’s own blood).
• Extracorporeal shockwave therapy (ESWT) – A device generates shock or pressure waves that are transferred to the tissue through the skin. This is supposed to improve the circulation of blood in the tissue and speed up the healing process.
• Laser therapy – The tissue is treated with concentrated beams of light. This is supposed to stimulate the circulation of blood and the body’s cell metabolism.
• Stretching and strengthening exercises: Special exercises that stretch and strengthen the muscles of the arm and wrist.
• Manual therapy – This includes active and passive exercises, as well as massages.
• Ultrasound therapy – The arm is exposed to high-frequency sound waves. This warms the tissue, which improves the circulation of blood.
• Transcutaneous electrical nerve stimulation (TENS) – TENS devices transfer electrical impulses to the nervous system through the skin. These are supposed to keep the pain signals from reaching the brain.
• Acupuncture – The acupuncture needles are inserted into certain points on the surface of the arm. Here, too, the aim is to minimize the perception of pain.
• Cold – The elbow is regularly cooled with ice packs.
• Massages –A massage technique called “transverse friction massage” is often used to treat tennis elbow and golfer’s elbow. It is applied to the tendons and the muscles, using the tips of one or two fingers.

Emergency department treatment and procedures

Elbow Joints Injuries are the most common cause of elbow pain. Some people may not recall having had a specific injury, especially if symptoms began gradually or during everyday activities. To better understand elbow injuries, you may want to review the structure and function of the elbow. See a picture of the elbow.

Dislocations may be isolated, involve damage to static supportive structures of the elbow, and may even cause fractures about the elbow. Because of this, it is important to recognize elbow dislocations and know the appropriate management to avoid any complications.

Your elbow joint is made up of bone, cartilage, ligaments, and fluid. Muscles and tendons help the elbow joint move. When any of these structures is hurt or diseased, you have elbow problems. Many things can make your elbow hurt. A common cause is a tendinitis, an inflammation or injury to the tendons that attach muscle to bone. Tendinitis of the elbow is a sports injury, often from playing tennis or golf. You may also get tendinitis from the overuse of the elbow. Other causes of elbow pain include sprains and strains, fractures (broken bones), dislocations, bursitis, and arthritis. Treatment depends on the cause.

Types of Elbow Joints Injuries

Sudden (acute) injury

An acute injury may be caused by a direct blow, penetrating injury, or fall or by twisting, jerking, jamming, or bending an elbow abnormally. Pain may be sudden and severe. Bruising and swelling may develop soon after the injury. Acute injuries include:

• Bruises from a tear or rupture of small blood vessels under the skin.
• Injuries to ligaments, the ropy fibers that connect bones to bones around joints.
• Injuries to tendons that connect muscles to bones.
• Injuries to joints (sprains) that stretch or tear the ligaments.
• Pulled muscles (strains) caused by overstretching muscles.
• Muscle tears or ruptures, such as your biceps or triceps in your upper arm.
• Broken bones (fractures) of the upper arm bone (humerus) or the forearm bones (ulna or radius) at the elbow joint.
• Dislocations of the elbow joint (out of its normal position).

Overuse injuries

Overuse injuries occur when too much stress is placed on a joint or other tissue, often by overdoing an activity or through repetition of an activity. Overuse injuries include:

• Bursitis. Swelling behind the elbow may be olecranon bursitis (Popeye elbow).
• Tendinosis, which is a series of microtears in the connective tissue in or around the tendon.
  • Soreness or pain felt on the outside (lateral) part of the elbow may be tennis elbow (lateral epicondylitis). This is the most common type of tendinopathy that affects the elbow and most often is caused by overuse of the forearm muscles. This overuse may occur during sports, such as tennis, swimming, golf, and sports involving throwing; jobs, such as carpentry or plumbing; or daily activities, such as lifting objects or gardening.
  • Soreness or pain in the inner (medial) part of the elbow may be golfer’s elbow. In children who participate in sports that involve throwing, the same elbow pain may be described as Little Leaguer’s elbow.
• Pinched nerves, such as ulnar nerve compression, which is the pinching of the ulnar nerve near the elbow joint. This usually occurs with repeated motions.

Supracondylar Fractures

This type of fracture involves the distal humerus just above the elbow. It is the most common type of elbow fracture and accounts for approximately 60% of all elbow fractures. It is considered an injury of the immature skeleton and occurs in young children between 5 to 10 years of age. Based on the mechanism of injury and the displacement of the distal fragment, professionals classify these as either extension or flexion type fractures.[rx][rx][rx] Beware that a nondisplaced fracture may be subtle and may only be recognized by one of the following:

• Posterior fat pad sign
• Anterior sail sign
• Disruption of the anterior humeral line

Radiographically, these fractures are classified into three types:

• Type I –  minimal or no displacement
• Type II – displaced fracture, posterior cortex intact
• Type III –  totally displaced fracture, anterior and posterior cortices disrupted

In a flexion type fracture that happens in less than 5% of cases, the elbow is displaced anteriorly. The typical mechanism is when a direct anterior force is applied against a flexed elbow, which causes anterior displacement of the distal fragment. With the displacement of the fragment, the periosteum tears posteriorly. Since the mechanism is a direct force, flexion type fractures are often open.[rx][rx][rx][rx]

• Type I fracture – non-displaced or minimally displaced
• Type II fractures – incomplete fracture; anterior cortex is intact
• Type III fracture – completely displaced; distal fragment migrates proximally and anteriorly

One of the most serious complications is neurovascular injury following the fracture, as the brachial artery and median nerve are located close to the site of the fracture and can be easily compromised.

Gartland Classification

Supracondylar fractures can be classified depending on the degree of displacement:

• Gartland Type 1 Fracture – Minimally displaced or occult fracture. The fracture is difficult to see on x-rays. The anterior humeral line still intersects the anterior half of the capitellum. The only visible sign on an x-ray will be a positive fat pad sign.
• Gartland Type 2 Fracture – Fracture that is displaced more posteriorly, but the posterior cortex remains intact.
• Gartland Type 3 Fracture – Completely displaced fracture with cortical disruption. Posteromedial displacement is more common happening in 75% of cases compared to posterolateral displacement which occurs in 25% of cases.

Lateral Condyle Fractures

• These types of fractures are the second most common type of elbow fracture in children and account for 15% to 20% of all elbow fractures. This fracture involves the lateral condyle of the distal humerus, which is the outer bony prominence of the elbow.
• The peak age for the occurrence of lateral condyle fractures is four to ten years old. Most commonly, these are Salter-Harris type IV ( a fracture that transects the metaphysis, physis, and epiphysis) involving the lateral condyle.

Two types of classifications are used to describe lateral condyle fractures

Milch classification

• Milch 1 – Less common type. Fracture line traverses laterally to the trochlear groove. Elbow is stable.
• Milch II – More common type. Fracture passes through the trochlear groove. Elbow is unstable.

Displacement Classification

• Type 1 – Displacement of less than 2 mm
• Type 2 –  more than 2 mm but less than 4 mm displacement. The fragment is close to the humerus
• Type 3 – Wide displacement, the articular surface is disrupted.

Medial Epicondyle Fractures

• These fractures are the third most common type of elbow fracture in children. It is an extra-articular fracture. It involves a fracture of the medial epicondyle apophysis, which is located on the posteromedial aspect of the elbow.  It commonly occurs in early adolescence, between the ages of nine to 14 years of age.
• It is more common in boys and occurs during athletic activities such as football, baseball, or gymnastics. The common mechanisms of injury are a posterior elbow dislocation and repeated valgus stress. An example is throwing a baseball repeatedly. One term for this is “little league elbow.”

A common presentation is medial elbow pain, tenderness over the medial epicondyle, and valgus instability.

Radial Head and Neck Fractures

• These fractures comprise about 1% to 5% of all pediatric elbow fractures. Most commonly these are Salter-Harris type II fractures that transect the physis and extend into the metaphysis for a short distance. This usually occurs between the ages of nine to ten years.

Olecranon Fractures

• Olecranon fractures are uncommon in children. These are mostly associated with radial head and neck fractures.

Causes of Elbow Joints Injuries

In general, elbow trauma can subdivide into the following categories:

Traumatic injuries

• Traumatic injuries range from simple contusions to more complex osseoligamentous fracture-dislocation patterns.  The latter is often seen following a fall on an outstretched hand while the forearm is supinated and the elbow is either partially flexed or fully extended

Attritional injuries

• Another form of elbow injuries consists of the subacute-to-chronic variety that occurs secondary to repetitive motions, eventually leading to various tendinosis conditions.  These can include but are not limited to, lateral epicondylitis (tennis elbow), and chronic partial UCL injuries or strains.[rx][rx]

Pediatric considerations

• Elbow trauma in children most commonly occurs via sport or following falls.  Moreover, careful attention during the assessment is necessary, given the characteristic sequence of ossification center appearance and fusion, which can make the radiographic assessment rather challenging.  Commonly encountered pediatric elbow fractures include (but are not limited to)[rx]

Another common elbow injury in children

• Subluxated radial head (nursemaid’s elbow)
• Accounts for 20% of all upper extremity injuries in children
• Peak age 1 to 4 years; occurs more frequently in females than males
• Mechanism of injury: sudden longitudinal pull on the forearm with forearm pronated

Signs and Symptoms of Elbow Joints Injuries

Symptoms include:

• The child stops using the arm, which is held in extension (or slightly bent) and palm down.^[rx]
• Minimal swelling.
• All movements are permitted except supination.
• Pain on the outer part of the elbow (lateral epicondyle)
• Point tenderness over the lateral epicondyle—a prominent part of the bone on the outside of the elbow
• Pain from gripping and movements of the wrist, especially wrist extension (e.g. turning a screwdriver) and lifting movements^[rx]
• Sudden intense pain at the back of the elbow will be felt at the time of injury.
• The patient will in most cases be unable to straighten the elbow.
• Rapid swelling and bruising may start to appear. Trying to move the elbow will be painful and the back of the elbow will be very tender to touch.
• Caused by longitudinal traction with the wrist in pronation, although in a series only 51% of people were reported to have this mechanism, with 22% reporting falls, and patients less than 6 months of age noted to have the injury after rolling over in bed.
• Symptoms include pain and tenderness on the inside of the elbow. Bruising and swelling may be present for more severe injuries.
• Impact injuries causing damage to the medial ligament usually involves a lateral force (towards the outside) being applied to the forearm, placing the medial (inner) joint under stress.
• The patient presents with swelling over the lateral elbow with a limited range of motion, particularly forearm rotation and elbow extension ± elbow effusion and bruising. Pain is increased with passive rotation.
• The most reliable clinical sign is point tenderness over the radial head.
• Needs careful assessment for nerve and vascular involvement, especially with brachial artery, median and ulnar nerves.
• It is important to detect crepitation or a mechanical blockage of motion from displaced fracture fragments. This often requires aspiration of a haemarthrosis with the installation of local anesthetic for pain relief.
• If there is significant wrist pain and/or central forearm pain, there may be acute longitudinal radioulnar dissociation with disruption of the distal radioulnar joint.
• Overuse injuries of the MCL may also occur. Repetitive motions that place a lot of stress on the inner elbow can cause damage to the ligament. For example, throwers (track and field and ball sports such as baseball) are prone to this injury. Especially if the technique is poor!

Diagnosis of Elbow Joints Injuries

Physical Examination

The examiner should perform and document relevant findings, including:

• Skin integrity

  • Critical when assessing for the presence of an open fracture and/or traumatic arthrotomy
• Presence of swelling or effusion
• Comprehensive neurovascular examination

How the patient carries their arm may give clues to the diagnosis.

Bony injuries

• Supracondylar fracture

  • Flexion type

    • Patient supports injured forearm with other arm and elbow in 90º flexion
    • Loss of olecranon prominence

  • Extension type

    • Patient hold arm at side in S-type configuration

Soft tissue injuries

• Elbow dislocations:

  • Posterior: abnormal prominence of olecranon
  • Anterior: loss of olecranon prominence

• Radial head subluxation

  • Elbow slightly flexed and forearm pronated resists moving the arm at the elbow

Sensory and motor testing of the Median and Ulnar nerves

Median

• Test for sensory function

  • Two-point discrimination over the tip of the index finger.

• Test for motor function

  • “OK” sign with thumb and index finger and abduction of the thumb (recurrent branch)

Ulnar

• Test for sensory function

  • Two-point discrimination of the little finger

• Test for motor function

  • Abduct index finger against resistance

Compartment Syndrome

Acute compartment syndrome can usually develop over a few hours after a serious injury. Some symptoms of acute compartment syndrome are:

• A new persistent deep pain
• Pain that seems greater than expected for the severity of the injury
• Numbness and tingling in the limb
• Swelling, tightness and bruising

Radiological Test

Radiographic studies that are necessary for all patients presenting with varying degrees of elbow trauma include:

• Anteroposterior (AP) elbow
• Lateral elbow
• Oblique views (optional, depending on fracture/injury)
• Traction view (optional, can facilitate the assessment of comminuted fracture patterns)

• Ipsilateral shoulder to wrist orthogonal views

  • Especially in the setting of high energy trauma or when exam and evaluation are limited

• Fat pad sign

  • Seen with intra-articular injuries
  • Normally, anterior fat pad is a narrow radiolucent strip anterior to humerus
  • The posterior fat pad is normally not visible
  • Anterior fat pad sign indicates joint effusion/ injury when raised and becomes more perpendicular to the anterior humeral cortex (sail sign)

  • Posterior fat pad sign indicates effusion/injury

    • In adults, posterior fat pad sign without other obvious fracture implies radial head fracture
    • In children, it implies supracondylar fracture

Pediatric Considerations

• Fractures in children often occur through unossified cartilage, making radiographic interpretation confusing
• A line of mensuration drawn down the anterior surface of the humerus should always bisect the capitellum in lateral view.
• If any bony relationship appears questionable on radiographs, obtain a comparison view of uninvolved elbow.
• Suspect nonaccidental trauma if history does not tip injury.

• Ossification centers: 1 appear: (CRITOE)

  • Capitellum 3 to 6 months
  • Radial head 3 to 5 years
  • Medial (Internal) epicondyle 5 to 7 years
  • Trochlea 9 to 10 years
  • Olecranon 9 to 10 years
  • Lateral Epicondyle

• It is essential to do bilateral radiographic imaging in pediatric cases.
• A nurse elbow can reduce spontaneously when the patient supinates the arm.

Advanced imaging sequences

Computerized tomography (CT) scans are often a consideration in the setting of comminuted fracture patterns for pre-operative surgical planning.  Magnetic resonance imaging (MRI) can be an option in the setting of soft tissue and ligamentous injury evaluation, or when suspecting stress or occult fractures.[rx][rx][rx]

Alert

Based on the complex anatomy of the elbow, a few things require attention:

• Neurovascular injuries to numerous structures that pass about the elbow, including anterior interosseous nerve, ulnar and radial nerves, brachial artery
• Volkmann ischemic contracture is compartment syndrome of the forearm

Differential Diagnosis

It is important to remember all possible diagnoses including (but not limited to):

• Fracture
• Dislocation
• Sprain
• Strain
• Ligamentous insufficiencies (e.g., UCL)
• Bursitis
• Tendinopathic conditions (acute or chronic)

Pediatric differential considerations include

• Child abuse

  • Distal humeral physeal injuries
• Nursemaids elbow
• Fracture(s)
• Avulsions
• Monteggia fracture-dislocations
• Physeal injuries/reactions

Treatment of Elbow Joints Injuries

Doctors sometimes recommend very different treatments for both tennis elbow and golfer’s elbow. According to the studies done so far, the following treatments can help:

• Rest, ice
• Physical therapy when appropriate – Eccentric exercises for lateral epicondylitis
• Braces/bandages – These are worn around the elbow or on the forearm to take the strain off the muscles.
• Injections – Injections into the elbow with various substances, such as Botox, hyaluronic acid or autologous blood (the body’s own blood).
• Extracorporeal shockwave therapy (ESWT) – A device generates shock or pressure waves that are transferred to the tissue through the skin. This is supposed to improve the circulation of blood in the tissue and speed up the healing process.
• Laser therapy – The tissue is treated with concentrated beams of light. This is supposed to stimulate the circulation of blood and the body’s cell metabolism.
• Stretching and strengthening exercises: Special exercises that stretch and strengthen the muscles of the arm and wrist.
• Manual therapy – This includes active and passive exercises, as well as massages.
• Ultrasound therapy – The arm is exposed to high-frequency sound waves. This warms the tissue, which improves the circulation of blood.
• Transcutaneous electrical nerve stimulation (TENS) – TENS devices transfer electrical impulses to the nervous system through the skin. These are supposed to keep the pain signals from reaching the brain.
• Acupuncture – The acupuncture needles are inserted into certain points on the surface of the arm. Here, too, the aim is to minimize the perception of pain.
• Cold – The elbow is regularly cooled with ice packs.
• Massages –A massage technique called “transverse friction massage” is often used to treat tennis elbow and golfer’s elbow. It is applied to the tendons and the muscles, using the tips of one or two fingers.

Emergency department treatment and procedures

Elbow Injuries are the most common cause of elbow pain. Some people may not recall having had a specific injury, especially if symptoms began gradually or during everyday activities. To better understand elbow injuries, you may want to review the structure and function of the elbow. See a picture of the elbow.

Dislocations may be isolated, involve damage to static supportive structures of the elbow, and may even cause fractures about the elbow. Because of this, it is important to recognize elbow dislocations and know the appropriate management to avoid any complications.

Your elbow joint is made up of bone, cartilage, ligaments, and fluid. Muscles and tendons help the elbow joint move. When any of these structures is hurt or diseased, you have elbow problems. Many things can make your elbow hurt. A common cause is a tendinitis, an inflammation or injury to the tendons that attach muscle to bone. Tendinitis of the elbow is a sports injury, often from playing tennis or golf. You may also get tendinitis from the overuse of the elbow. Other causes of elbow pain include sprains and strains, fractures (broken bones), dislocations, bursitis, and arthritis. Treatment depends on the cause.

Types of Elbow Injuries

Sudden (acute) injury

An acute injury may be caused by a direct blow, penetrating injury, or fall or by twisting, jerking, jamming, or bending an elbow abnormally. Pain may be sudden and severe. Bruising and swelling may develop soon after the injury. Acute injuries include:

• Bruises from a tear or rupture of small blood vessels under the skin.
• Injuries to ligaments, the ropy fibers that connect bones to bones around joints.
• Injuries to tendons that connect muscles to bones.
• Injuries to joints (sprains) that stretch or tear the ligaments.
• Pulled muscles (strains) caused by overstretching muscles.
• Muscle tears or ruptures, such as your biceps or triceps in your upper arm.
• Broken bones (fractures) of the upper arm bone (humerus) or the forearm bones (ulna or radius) at the elbow joint.
• Dislocations of the elbow joint (out of its normal position).

Overuse injuries

Overuse injuries occur when too much stress is placed on a joint or other tissue, often by overdoing an activity or through repetition of an activity. Overuse injuries include:

• Bursitis. Swelling behind the elbow may be olecranon bursitis (Popeye elbow).
• Tendinosis, which is a series of microtears in the connective tissue in or around the tendon.
  • Soreness or pain felt on the outside (lateral) part of the elbow may be tennis elbow (lateral epicondylitis). This is the most common type of tendinopathy that affects the elbow and most often is caused by overuse of the forearm muscles. This overuse may occur during sports, such as tennis, swimming, golf, and sports involving throwing; jobs, such as carpentry or plumbing; or daily activities, such as lifting objects or gardening.
  • Soreness or pain in the inner (medial) part of the elbow may be golfer’s elbow. In children who participate in sports that involve throwing, the same elbow pain may be described as Little Leaguer’s elbow.
• Pinched nerves, such as ulnar nerve compression, which is the pinching of the ulnar nerve near the elbow joint. This usually occurs with repeated motions.

Supracondylar Fractures

This type of fracture involves the distal humerus just above the elbow. It is the most common type of elbow fracture and accounts for approximately 60% of all elbow fractures. It is considered an injury of the immature skeleton and occurs in young children between 5 to 10 years of age. Based on the mechanism of injury and the displacement of the distal fragment, professionals classify these as either extension or flexion type fractures.[rx][rx][rx] Beware that a nondisplaced fracture may be subtle and may only be recognized by one of the following:

• Posterior fat pad sign
• Anterior sail sign
• Disruption of the anterior humeral line

Radiographically, these fractures are classified into three types:

• Type I –  minimal or no displacement
• Type II – displaced fracture, posterior cortex intact
• Type III –  totally displaced fracture, anterior and posterior cortices disrupted

In a flexion type fracture that happens in less than 5% of cases, the elbow is displaced anteriorly. The typical mechanism is when a direct anterior force is applied against a flexed elbow, which causes anterior displacement of the distal fragment. With the displacement of the fragment, the periosteum tears posteriorly. Since the mechanism is a direct force, flexion type fractures are often open.[rx][rx][rx][rx]

• Type I fracture – non-displaced or minimally displaced
• Type II fractures – incomplete fracture; anterior cortex is intact
• Type III fracture – completely displaced; distal fragment migrates proximally and anteriorly

One of the most serious complications is neurovascular injury following the fracture, as the brachial artery and median nerve are located close to the site of the fracture and can be easily compromised.

Gartland Classification

Supracondylar fractures can be classified depending on the degree of displacement:

• Gartland Type 1 Fracture – Minimally displaced or occult fracture. The fracture is difficult to see on x-rays. The anterior humeral line still intersects the anterior half of the capitellum. The only visible sign on an x-ray will be a positive fat pad sign.
• Gartland Type 2 Fracture – Fracture that is displaced more posteriorly, but the posterior cortex remains intact.
• Gartland Type 3 Fracture – Completely displaced fracture with cortical disruption. Posteromedial displacement is more common happening in 75% of cases compared to posterolateral displacement which occurs in 25% of cases.

Lateral Condyle Fractures

• These types of fractures are the second most common type of elbow fracture in children and account for 15% to 20% of all elbow fractures. This fracture involves the lateral condyle of the distal humerus, which is the outer bony prominence of the elbow.
• The peak age for the occurrence of lateral condyle fractures is four to ten years old. Most commonly, these are Salter-Harris type IV ( a fracture that transects the metaphysis, physis, and epiphysis) involving the lateral condyle.

Two types of classifications are used to describe lateral condyle fractures

Milch classification

• Milch 1 – Less common type. Fracture line traverses laterally to the trochlear groove. Elbow is stable.
• Milch II – More common type. Fracture passes through the trochlear groove. Elbow is unstable.

Displacement Classification

• Type 1 – Displacement of less than 2 mm
• Type 2 –  more than 2 mm but less than 4 mm displacement. The fragment is close to the humerus
• Type 3 – Wide displacement, the articular surface is disrupted.

Medial Epicondyle Fractures

• These fractures are the third most common type of elbow fracture in children. It is an extra-articular fracture. It involves a fracture of the medial epicondyle apophysis, which is located on the posteromedial aspect of the elbow.  It commonly occurs in early adolescence, between the ages of nine to 14 years of age.
• It is more common in boys and occurs during athletic activities such as football, baseball, or gymnastics. The common mechanisms of injury are a posterior elbow dislocation and repeated valgus stress. An example is throwing a baseball repeatedly. One term for this is “little league elbow.”

A common presentation is medial elbow pain, tenderness over the medial epicondyle, and valgus instability.

Radial Head and Neck Fractures

• These fractures comprise about 1% to 5% of all pediatric elbow fractures. Most commonly these are Salter-Harris type II fractures that transect the physis and extend into the metaphysis for a short distance. This usually occurs between the ages of nine to ten years.

Olecranon Fractures

• Olecranon fractures are uncommon in children. These are mostly associated with radial head and neck fractures.

Causes of Elbow Injuries

In general, elbow trauma can subdivide into the following categories:

Traumatic injuries

• Traumatic injuries range from simple contusions to more complex osseoligamentous fracture-dislocation patterns.  The latter is often seen following a fall on an outstretched hand while the forearm is supinated and the elbow is either partially flexed or fully extended

Attritional injuries

• Another form of elbow injuries consists of the subacute-to-chronic variety that occurs secondary to repetitive motions, eventually leading to various tendinosis conditions.  These can include but are not limited to, lateral epicondylitis (tennis elbow), and chronic partial UCL injuries or strains.[rx][rx]

Pediatric considerations

• Elbow trauma in children most commonly occurs via sport or following falls.  Moreover, careful attention during the assessment is necessary, given the characteristic sequence of ossification center appearance and fusion, which can make the radiographic assessment rather challenging.  Commonly encountered pediatric elbow fractures include (but are not limited to)[rx]

Another common elbow injury in children

• Subluxated radial head (nursemaid’s elbow)
• Accounts for 20% of all upper extremity injuries in children
• Peak age 1 to 4 years; occurs more frequently in females than males
• Mechanism of injury: sudden longitudinal pull on the forearm with forearm pronated

Signs and Symptoms of Elbow Injuries

Symptoms include:

• The child stops using the arm, which is held in extension (or slightly bent) and palm down.^[rx]
• Minimal swelling.
• All movements are permitted except supination.
• Pain on the outer part of the elbow (lateral epicondyle)
• Point tenderness over the lateral epicondyle—a prominent part of the bone on the outside of the elbow
• Pain from gripping and movements of the wrist, especially wrist extension (e.g. turning a screwdriver) and lifting movements^[rx]
• Sudden intense pain at the back of the elbow will be felt at the time of injury.
• The patient will in most cases be unable to straighten the elbow.
• Rapid swelling and bruising may start to appear. Trying to move the elbow will be painful and the back of the elbow will be very tender to touch.
• Caused by longitudinal traction with the wrist in pronation, although in a series only 51% of people were reported to have this mechanism, with 22% reporting falls, and patients less than 6 months of age noted to have the injury after rolling over in bed.
• Symptoms include pain and tenderness on the inside of the elbow. Bruising and swelling may be present for more severe injuries.
• Impact injuries causing damage to the medial ligament usually involves a lateral force (towards the outside) being applied to the forearm, placing the medial (inner) joint under stress.
• The patient presents with swelling over the lateral elbow with a limited range of motion, particularly forearm rotation and elbow extension ± elbow effusion and bruising. Pain is increased with passive rotation.
• The most reliable clinical sign is point tenderness over the radial head.
• Needs careful assessment for nerve and vascular involvement, especially with brachial artery, median and ulnar nerves.
• It is important to detect crepitation or a mechanical blockage of motion from displaced fracture fragments. This often requires aspiration of a haemarthrosis with the installation of local anesthetic for pain relief.
• If there is significant wrist pain and/or central forearm pain, there may be acute longitudinal radioulnar dissociation with disruption of the distal radioulnar joint.
• Overuse injuries of the MCL may also occur. Repetitive motions that place a lot of stress on the inner elbow can cause damage to the ligament. For example, throwers (track and field and ball sports such as baseball) are prone to this injury. Especially if the technique is poor!

Diagnosis of Elbow Injuries

Physical Examination

The examiner should perform and document relevant findings, including:

• Skin integrity

  • Critical when assessing for the presence of an open fracture and/or traumatic arthrotomy
• Presence of swelling or effusion
• Comprehensive neurovascular examination

How the patient carries their arm may give clues to the diagnosis.

Bony injuries

• Supracondylar fracture

  • Flexion type

    • Patient supports injured forearm with other arm and elbow in 90º flexion
    • Loss of olecranon prominence

  • Extension type

    • Patient hold arm at side in S-type configuration

Soft tissue injuries

• Elbow dislocations:

  • Posterior: abnormal prominence of olecranon
  • Anterior: loss of olecranon prominence

• Radial head subluxation

  • Elbow slightly flexed and forearm pronated resists moving the arm at the elbow

Sensory and motor testing of the Median and Ulnar nerves

Median

• Test for sensory function

  • Two-point discrimination over the tip of the index finger.

• Test for motor function

  • “OK” sign with thumb and index finger and abduction of the thumb (recurrent branch)

Ulnar

• Test for sensory function

  • Two-point discrimination of the little finger

• Test for motor function

  • Abduct index finger against resistance

Compartment Syndrome

Acute compartment syndrome can usually develop over a few hours after a serious injury. Some symptoms of acute compartment syndrome are:

• A new persistent deep pain
• Pain that seems greater than expected for the severity of the injury
• Numbness and tingling in the limb
• Swelling, tightness and bruising

Radiological Test

Radiographic studies that are necessary for all patients presenting with varying degrees of elbow trauma include:

• Anteroposterior (AP) elbow
• Lateral elbow
• Oblique views (optional, depending on fracture/injury)
• Traction view (optional, can facilitate the assessment of comminuted fracture patterns)

• Ipsilateral shoulder to wrist orthogonal views

  • Especially in the setting of high energy trauma or when exam and evaluation are limited

• Fat pad sign

  • Seen with intra-articular injuries
  • Normally, anterior fat pad is a narrow radiolucent strip anterior to humerus
  • The posterior fat pad is normally not visible
  • Anterior fat pad sign indicates joint effusion/ injury when raised and becomes more perpendicular to the anterior humeral cortex (sail sign)

  • Posterior fat pad sign indicates effusion/injury

    • In adults, posterior fat pad sign without other obvious fracture implies radial head fracture
    • In children, it implies supracondylar fracture

Pediatric Considerations

• Fractures in children often occur through unossified cartilage, making radiographic interpretation confusing
• A line of mensuration drawn down the anterior surface of the humerus should always bisect the capitellum in lateral view.
• If any bony relationship appears questionable on radiographs, obtain a comparison view of uninvolved elbow.
• Suspect nonaccidental trauma if history does not tip injury.

• Ossification centers: 1 appear: (CRITOE)

  • Capitellum 3 to 6 months
  • Radial head 3 to 5 years
  • Medial (Internal) epicondyle 5 to 7 years
  • Trochlea 9 to 10 years
  • Olecranon 9 to 10 years
  • Lateral Epicondyle

• It is essential to do bilateral radiographic imaging in pediatric cases.
• A nurse elbow can reduce spontaneously when the patient supinates the arm.

Advanced imaging sequences

Computerized tomography (CT) scans are often a consideration in the setting of comminuted fracture patterns for pre-operative surgical planning.  Magnetic resonance imaging (MRI) can be an option in the setting of soft tissue and ligamentous injury evaluation, or when suspecting stress or occult fractures.[rx][rx][rx]

Alert

Based on the complex anatomy of the elbow, a few things require attention:

• Neurovascular injuries to numerous structures that pass about the elbow, including anterior interosseous nerve, ulnar and radial nerves, brachial artery
• Volkmann ischemic contracture is compartment syndrome of the forearm

Differential Diagnosis

It is important to remember all possible diagnoses including (but not limited to):

• Fracture
• Dislocation
• Sprain
• Strain
• Ligamentous insufficiencies (e.g., UCL)
• Bursitis
• Tendinopathic conditions (acute or chronic)

Pediatric differential considerations include

• Child abuse

  • Distal humeral physeal injuries
• Nursemaids elbow
• Fracture(s)
• Avulsions
• Monteggia fracture-dislocations
• Physeal injuries/reactions

Treatment of Elbow Injuries

Doctors sometimes recommend very different treatments for both tennis elbow and golfer’s elbow. According to the studies done so far, the following treatments can help:

• Rest, ice
• Physical therapy when appropriate – Eccentric exercises for lateral epicondylitis
• Braces/bandages – These are worn around the elbow or on the forearm to take the strain off the muscles.
• Injections – Injections into the elbow with various substances, such as Botox, hyaluronic acid or autologous blood (the body’s own blood).
• Extracorporeal shockwave therapy (ESWT) – A device generates shock or pressure waves that are transferred to the tissue through the skin. This is supposed to improve the circulation of blood in the tissue and speed up the healing process.
• Laser therapy – The tissue is treated with concentrated beams of light. This is supposed to stimulate the circulation of blood and the body’s cell metabolism.
• Stretching and strengthening exercises: Special exercises that stretch and strengthen the muscles of the arm and wrist.
• Manual therapy – This includes active and passive exercises, as well as massages.
• Ultrasound therapy – The arm is exposed to high-frequency sound waves. This warms the tissue, which improves the circulation of blood.
• Transcutaneous electrical nerve stimulation (TENS) – TENS devices transfer electrical impulses to the nervous system through the skin. These are supposed to keep the pain signals from reaching the brain.
• Acupuncture – The acupuncture needles are inserted into certain points on the surface of the arm. Here, too, the aim is to minimize the perception of pain.
• Cold – The elbow is regularly cooled with ice packs.
• Massages –A massage technique called “transverse friction massage” is often used to treat tennis elbow and golfer’s elbow. It is applied to the tendons and the muscles, using the tips of one or two fingers.

Emergency department treatment and procedures