Elbow Joints Fractures – Causes, Symptoms, Treatment

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

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