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Elbow Injuries, Emergency Medicine

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Elbow Injuries, Emergency Medicine

Basics

Description

How patient carries arm may give clues to diagnosis.

Immobilization to prevent further injury before taking radiographs is essential.

  • Supracondylar fracture:Most common in childrenPeak ages 5-10 yr, rarely occurs >15 yrExtension type (98%): Fall on outstretched hand (FOOSH) with fully extended or hyperextended arm:Type 1: Minimal or no displacementType 2: Slightly displaced fracture; posterior cortex intactType 3: Totally displaced fracture; posterior cortex brokenFlexion type: Blow directly to flexed elbow:Type 1: Minimal or no displacementType 2: Slightly displaced fracture; anterior cortex intactType 3: Totally displaced fracture; anterior cortex broken
  • Radial head fracture:Usually indirect mechanism (e.g., FOOSH)Radial head driven into capitellum
  • 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 displacementType 2: Slightly displaced fracture; posterior cortex intactType 3: Totally displaced fracture; posterior cortex broken
  • Flexion type: Blow directly to flexed elbow:Type 1: Minimal or no displacementType 2: Slightly displaced fracture; anterior cortex intactType 3: Totally displaced fracture; anterior cortex broken
  • Type 1: Minimal or no displacement
  • Type 2: Slightly displaced fracture; posterior cortex intact
  • Type 3: Totally displaced fracture; posterior cortex broken
  • Type 1: Minimal or no displacement
  • Type 2: Slightly displaced fracture; anterior cortex intact
  • Type 3: Totally displaced fracture; anterior cortex broken
  • Usually indirect mechanism (e.g., FOOSH)
  • Radial head driven into capitellum
  • Elbow dislocation:2nd only to shoulder as most dislocated jointMost are posterior.
  • Medial/lateral epicondylitis:Overuse injuries usually related to rotary motion at elbowInvolving attachment points of hand and wrist flexor/extensor groups to elbowPlumbers, carpenters, tennis players, golfersPain made worse by resisted contraction of particular muscle groups
  • 2nd only to shoulder as most dislocated joint
  • Most are posterior.
  • 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

  • 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.
  • Patient supports injured forearm with other arm and elbow in 90 ° flexion.
  • Loss of olecranon prominence
  • Patient holds arm at side in S-type configuration.
  • Elbow dislocations:Posterior: Abnormal prominence of olecranonAnterior: 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 forearmPain increases with grasping and twisting motions.
  • Posterior: Abnormal prominence of olecranon
  • Anterior: Loss of olecranon prominence
  • Elbow slightly flexed and forearm pronated, resists moving arm at elbow
  • 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

  • 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 injuriesNormally, 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.
  • 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.
  • 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 moRadial head: 3-5 yrMedial epicondyle: 5-7 yrTrochlea: 9-10 yrOlecranon: 9-10 yrLateral epicondyle: 9-13 yr
  • 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

Initial Stabilization/Therapy

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 fracturesFractures 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 reductionIf 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
  • Transcondylar, intercondylar, condylar, epicondylar fractures
  • Fractures involving articular surfaces such as capitellum or trochlea
  • 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.
  • Reduce immediately if vascular structures compromised.
  • Then flex to 90 ° and place posterior splint.
  • Reduce immediately if vascular structures compromised.
  • Then flex to 90 ° and place posterior splint.
  • Minimally displaced fractures may be aspirated to remove hemarthrosis; instill bupivacaine (Marcaine) and immobilize.
  • Other types should have orthopedic consult.
  • 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.
  • 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

  • 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.
  • 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