Basics
Description
Bony Injuries
- Supracondylar fracture:
- Most common in children
- Peak ages 5-10 yr, rarely occurs >15 yr
- Extension type (98%): Fall on outstretched hand (FOOSH) with fully extended or hyperextended arm:
- Type 1: Minimal or no displacement
- Type 2: Slightly displaced fracture; posterior cortex intact
- Type 3: Totally displaced fracture; posterior cortex broken
- Flexion type: Blow directly to flexed elbow:
- Type 1: Minimal or no displacement
- Type 2: Slightly displaced fracture; anterior cortex intact
- Type 3: Totally displaced fracture; anterior cortex broken
- Radial head fracture:
- Usually indirect mechanism (e.g., FOOSH)
- Radial head driven into capitellum
Soft Tissue Injuries
- Elbow dislocation:
- 2nd only to shoulder as most dislocated joint
- Most are posterior.
- Medial/lateral epicondylitis:
- Overuse injuries usually related to rotary motion at elbow
- Involving attachment points of hand and wrist flexor/extensor groups to elbow
- Plumbers, carpenters, tennis players, golfers
- Pain made worse by resisted contraction of particular muscle groups
- Subluxed radial head (nursemaids elbow)
- 20% of all upper extremity injuries in children
- Peak age 1-4 yr; occurs more frequently in females than males
- Sudden longitudinal pull on forearm with forearm pronated
Etiology
- Mechanism aids in determining expected injury.
- Trauma predominates.
- Most elbow injuries caused by indirect trauma are transmitted through bones of forearm (e.g., FOOSH)
- Direct blows account for very few fractures or dislocations.
Diagnosis
Signs and Symptoms
How patient carries arm may give clues to diagnosis.
Bony Injuries
Supracondylar fracture:
- Flexion type:
- Patient supports injured forearm with other arm and elbow in 90 ° flexion.
- Loss of olecranon prominence
- Extension type:
- Patient holds 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 arm at elbow
- Medial/lateral epicondylitis:
- Gradual onset of dull ache over inner/outer aspect of elbow referred to forearm
- Pain increases with grasping and twisting motions.
Essential Workup
- Radiographs
- Assess wrist and shoulder for associated injury.
- Evaluate neurovascular status of limb.
- Assess skin integrity.
- Examine for compartment syndrome, which is more common in supracondylar fractures.
- Injuries to ipsilateral upper limb, particularly fractures to midshaft humerus and distal forearm, are common.
- Evaluate for associated neurovascular injuries (up to 20%).
Diagnosis Tests & Interpretation
Lab
None specific for elbow injuries
Imaging
- Not usually necessary if overuse injury suspected
- Routine anteroposterior (AP) and lateral; add oblique for assessment of subtle injuries to radial head/distal humerus.
- Fat pad sign:
- Seen with intra-articular injuries
- Normally, anterior fat pad is a narrow radiolucent strip anterior to humerus.
- Posterior fat pad is normally not visible.
- Anterior fat pad sign indicates joint effusion/injury when raised and becomes more perpendicular to 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.
- Fractures in children often occur through unossified cartilage, making radiographic interpretation confusing.
- A line drawn down the anterior surface of humerus should always bisect the capitellum in lateral view.
- If any bony relationships appear questionable on radiographs, obtain comparison view of uninvolved elbow.
- Suspect nonaccidental trauma if history does not fit injury.
- Ossification centers: 1st appear:
- Capitellum: 3-6 mo
- Radial head: 3-5 yr
- Medial epicondyle: 5-7 yr
- Trochlea: 9-10 yr
- Olecranon: 9-10 yr
- Lateral epicondyle: 9-13 yr
Differential Diagnosis
- Sprain/strain
- Effusion
- Contusion
- Bursitis
- Arthritis
Treatment
Pre-Hospital
Appropriate splinting
Initial Stabilization/Therapy
Immobilization to prevent further injury before taking radiographs is essential.
Ed Treatment/Procedures
- Orthopedic consultation is recommended for all but nondisplaced, stable fractures, which can generally be splinted with 24-48 hr orthopedic follow-up.
- Fractures generally requiring orthopedic consultation:
- Transcondylar, intercondylar, condylar, epicondylar fractures
- Fractures involving articular surfaces such as capitellum or trochlea
- Supracondylar fractures:
- Type 1 can be handled by ED physician with 24-48 hr orthopedic follow-up.
- Elbow may be flexed and splinted with posterior splint.
- Types 2 and 3 require immediate orthopedic consult.
- Reduce these in ED when fracture is associated with vascular compromise.
- Anterior dislocation:
- Reduce immediately if vascular structures compromised.
- Then flex to 90 ° and place posterior splint.
- Posterior dislocation:
- Reduce immediately if vascular structures compromised.
- Then flex to 90 ° and place posterior splint.
- Radial head fracture:
- Minimally displaced fractures may be aspirated to remove hemarthrosis; instill bupivacaine (Marcaine) and immobilize.
- Other types should have orthopedic consult.
- Radial head subluxation:
- In 1 continuous motion, supinate and flex elbow while placing slight pressure on radial head.
- Hyperpronation technique is possibly more effective-while grasping the patients elbow the wrist is hyperpronated until a palpable click is felt.
- Often will feel click with reduction
- If exam suggests fracture but radiograph is negative, splint and have patient follow up in 24-48 hr for re-evaluation.
- Medial/lateral epicondylitis:
- Severe cases can be splinted.
- Rest, heat, anti-inflammatory agents
- 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 forearm.
Medication
- Conscious sedation is often required to achieve reductions; see Conscious Sedation.
- Ibuprofen: 600-800 mg (peds: 5-10 mg/kg) PO TID
- Naprosyn: 250-500 mg (peds: 10-20 mg/kg) PO BID
- Tylenol with codeine no. 3: 1 or 2 tabs (peds: 0.5-1 mg/kg codeine) PO q4-6h; Do not exceed acetaminophen 4 g/24h
- Morphine sulfate: 0.1 mg/kg IV q2-6h
- Hydromorphone 5 mg/Acetaminophen 300 mg
- Acetaminophen do not exceed 4 g/24h
- Vicodin: 1-2 tabs PO q4-6h
Follow-Up
Disposition
Admission Criteria
- Vascular injuries, open fractures
- Fractures requiring operative reduction or internal fixation
- Admit all patients with extensive swelling or ecchymosis for overnight observation and elevation to monitor for and decrease risk for compartment syndrome.
Discharge Criteria
- Stable fractures or reduced dislocations with none of the above features
- Splint and arrange orthopedic follow-up in 24-48 hr.
- Uncomplicated soft tissue injuries
Pearls and Pitfalls
- Failure to appreciate that a posterior fat pad sign is abnormal.
- Always check for neurovascular injury with injuries about the elbow, especially with dislcoations, pre- and postreduction.
- Always educate parents of a child with a supracondylar fracture about the signs and symptoms of compartment syndrome.
Additional Reading
- Carson S, Woolridge DP, Colletti J, et al. Pediatric upper extremity injuries. Pediatr Clin North Am. 2006;53(1):41-67.
- Carter SJ, Germann CA, Dacus AA, et al. Orthopedic pitfalls in the ED: Neurovascular injury associated with posterior elbow dislocations. Am J Emerg Med. 2010;28(8):960-965.
- Chasm RM, Swencki SA. Pediatric orthopedic emergencies. Emerg Med Clin North Am. 2010;28(4):907-926.
- Falcon-Chevere JL, Mathew D, Cabanas JG, et al. Management and treatment of elbow and forearm injuries. Emerg Med Clin North Am. 2010;28(4):765-787.
- McCarty LP, Ring D, Jupiter JB. Management of distal humerus fractures. Am J Orthop (Belle Mead NJ). 2005;34(9):430-438.
Codes
ICD9
- 812.41 Closed supracondylar fracture of humerus
- 813.05 Closed fracture of head of radius
- 959.3 Elbow, forearm, and wrist injury
- 832.00 Closed dislocation of elbow, unspecified
- 726.31 Medial epicondylitis
- 726.32 Lateral epicondylitis
- 832.02 Closed posterior dislocation of elbow
ICD10
- S42.414A Nondisp simple suprcndl fx w/o intrcndl fx r humerus, init
- S52.126A Nondisp fx of head of unsp radius, init for clos fx
- S59.909A Unspecified injury of unspecified elbow, initial encounter
- S53.106A Unsp dislocation of unsp ulnohumeral joint, init encntr
- M77.00 Medial epicondylitis, unspecified elbow
- M77.10 Lateral epicondylitis, unspecified elbow
- S42.413A Displ simple suprcndl fx w/o intrcndl fx unsp humerus, init
- S52.123A Disp fx of head of unsp radius, init for clos fx
- S53.126A Posterior dislocation of unsp ulnohumeral joint, init encntr
SNOMED
- 125596004 injury of elbow (disorder)
- 263193000 Supracondylar fracture of humerus (disorder)
- 263196008 fracture of radial head (disorder)
- 417558002 Dislocation of elbow joint (disorder)
- 202855006 Lateral epicondylitis (disorder)
- 53286005 Medial epicondylitis