Elbow fractures can be divided into those of the distal humerus,
proximal ulna, and proximal radius. The distal humerus includes
the condylar structures and the articular surface (trochlea and
capitellum). The proximal ulna includes the coronoid process and
olecranon, and the proximal radius is essentially the radial head.
Radiographs of fractures about the elbow may reveal abnormal
fat pads (Figure 267-8).11 Normally,
a posterior fat pad is not visible, and normally, an anterior fat
pad may be visible as a thin lucent stripe. With injury, fat
from the olecranon fossa is displaced posteriorly (posterior fat
pad), and the anterior fat pad may become quite prominent (“sail sign”)
due to hemarthrosis. Abnormal fat pads may also be seen with nontraumatic
joint effusions. Furthermore, they may be absent in severe trauma
that disrupts the joint capsule and allows intra-articular fluid
extravasation. In some nondisplaced fractures, the
fracture line may not be seen, with the fat pad sign being the only
evidence of injury. Treatment is initiated as though a fracture
were identified, with splint immobilization and orthopedic consultation.
Routine ED care of nondisplaced distal humerus fractures with
normal neurovascular function includes immobilization, ice, elevation,
analgesics, and orthopedic referral. Displaced fractures or those
with neurovascular compromise require immediate orthopedic consultation.
See Chapter 268, Shoulder and Humerus Injuries, for
a detailed discussion of shoulder and humerus injuries.
Supracondylar fractures are the most common fracture about the
elbow in children. They can be either extension type (>95%),
which are displaced posteriorly, or flexion type (<5%),
which are displaced anteriorly.12 The most commonly
used classification for supracondylar fractures is the Gartland,
based on degree of displacement (Table 267-1.1).13 There
can also be various degrees of abduction, adduction, and rotation of
the distal fragment.14
Table 267-1.1 Gartland Classification
of Pediatric Supracondylar Fractures |Favorite Table|Download (.pdf)
Table 267-1.1 Gartland Classification
of Pediatric Supracondylar Fractures
|Displaced, but posterior cortex intact|
|Displaced, but anterior cortex intact|
As the name implies, these injuries most often occur with a fall
on an outstretched hand with the elbow in full extension. The patient
will have significant edema and tenderness at the elbow, a prominent
olecranon, and a depression proximal to the elbow. The appearance
may be easily mistaken for a posterior elbow dislocation. In displaced
fractures, the anteroposterior radiograph usually reveals a transverse
fracture line. More severely displaced fractures may show medial
or lateral displacement, or rotation along the axis of the humerus
(Figure 267-9). The lateral radiograph will
reveal the fracture line extending obliquely from posterior proximal
to anterior distal. The distal fragment will be displaced proximally
and posteriorly. Displaced fractures must be reduced and require
emergent orthopedic consultation. Indications for open reduction
are vascular insufficiency with a probable entrapped brachial artery
in the fracture site or an irreducible fracture. Patients with displaced
fractures or significant soft tissue swelling should be admitted
for observation of neurovascular function.
Extension type, displaced supracondylar fracture.
Flexion type fractures are rare. The mechanism of injury is a
direct anterior force against a flexed elbow, resulting in anterior
displacement of the distal fragment. Because the mechanism is direct
force, these fractures are often open. Radiographs reveal an oblique
fracture from anterior proximal to posterior distal. The distal
fragment is anterior to the humerus. Displaced fractures must be reduced
and require immediate orthopedic consultation. Indications for open
reduction are vascular insufficiency with a probable entrapped brachial
artery in the fracture site or an irreducible fracture. Patients
with displaced fractures or significant soft tissue swelling should
be admitted for observation of neurovascular function.
of Supracondylar Fractures
There are numerous potential complications of supracondylar fractures
(Table 267-2). Neurologic complications—resulting
from traction, direct trauma, or nerve ischemia—have an
incidence of 7%. Posteromedial displacement may involve the radial nerve, and posterolateral
displacement usually affects the median nerve. Ulnar nerve
injuries are uncommon, with the highest incidence reported from
pin placement. However, a high incidence has been noted of anterior
interosseous nerve injuries with supracondylar fractures. This
nerve arises from the median nerve. The mechanism of injury is usually
traction or contusion. Complete transection is rare, and entrapment
within the fracture occurs only occasionally. Because there
is no sensory component to the anterior interosseous nerve, identification
of the injury can be made only by motor testing, which consists
of flexion at the index finger distal interphalangeal and thumb
interphalangeal joints (making the “OK” sign). Patients
usually regain full flexion and strength after 4 to 17 weeks.14
Table 267-2 Complications
of Supracondylar Fractures |Favorite Table|Download (.pdf)
Table 267-2 Complications
of Supracondylar Fractures
|Median nerve (anterior interosseous branch)|
|Volkmann ischemic contracture (compartment syndrome
of the forearm)|
|Loss of motion|
Acute vascular injuries must always be suspected in patients
with supracondylar fractures. Absence of a radial pulse is common
in children, which is most frequently due to transient arterial
spasm. Rarely, there is a partial or complete transection, an intimal
tear and thrombosis, or entrapment within the fracture fragment
of the brachial artery.
The most serious complication is a compartment syndrome
of the forearm, also known as Volkmann ischemic
contracture. This classically occurs following
a supracondylar fracture. Postischemic swelling, producing increased
pressure within the enclosed osteofascial forearm compartment, reduces
capillary blood perfusion below the level necessary for tissue viability.
If unrelieved, the end result is muscle and nerve necrosis, and
eventual replacement by fibrotic tissue, producing a contracture.
Refusal to open the hand in children, pain with passive extension
of the fingers, and forearm tenderness are signs of impending Volkmann
ischemia. It is now well understood that the mere lack of
a radial pulse does not indicate ischemia unless accompanied by
Treatment of supracondylar fractures with absent radial pulse
begins with closed reduction and percutaneous pinning. Extremities
still without a pulse and with signs of ischemia are taken to the
operating room for fasciotomy and brachial artery exploration.
Intercondylar fractures, in which the condylar fragments are
separated, are much more common in adults than in children. Any
distal humerus fracture in an adult should initially be assumed
to be intercondylar rather than supracondylar. A careful search
should be made for a fracture line separating the condyles from
each other and from the humerus. There are numerous classification
systems for intercondylar fractures, which include the T and Y classification.
This includes the high and low T, Y, H, and medial and lateral lambda
fractures (Figure 267-10).15–17 Regardless
of the classification system used, intraobserver and interobserver
agreement varies, as does radiographic and intraoperative diagnosis.
A through F. Intercondylar
fracture classification of Mehne and Matta. (Reproduced with permission
from Jupiter JB: Internal fixation for fracture about the elbow. Op
Tech Orthop 4: 34, 1994.)
The mechanism of injury is a force directed against the posterior
elbow, driving the olecranon against the humeral articular surface,
separating the condyles and producing the typical fracture. Intercondylar
fractures are associated with severe soft tissue injuries. Treatment
in the young is directed at anatomic reduction. In older patients
with severe injuries, treatment is often directed at reestablishing
articular surface congruity. If this cannot be achieved by closed
methods, then the integrity of the articular surface is restored
by an open reduction. As in supracondylar fractures, patients with
severe edema or displaced fractures should be admitted.
Lateral epicondyle fractures almost never occur, because the
anatomic position of the condyle reduces its exposure to direct
blows, resulting instead in fractures of the lateral condyle. When
they do occur, lateral epicondyle fractures are usually avulsion
fractures and may be treated by long arm posterior mold, with the
elbow flexed to 90 degrees and the forearm in supination, and orthopedic
Isolated medial epicondyle fractures are considered extra-articular
injuries, and usually occur in children and adolescents. Mechanisms
include a posterior elbow dislocation, repeated valgus stress, such
as throwing a baseball (Little League elbow), or a direct blow.
If there is an associated tear of the medial collateral ligament,
the epicondyle itself may become entrapped in the joint space. Patients
present with pain over the medial elbow that is exacerbated by supination
of the forearm and flexion of the forearm, wrist, and digits. Edema
and tenderness are noted in the same area. Standard radiographs
are obtained with special attention to any intra-articular fragment.
Carefully test ulnar nerve function. Nondisplaced or minimally displaced
medial epicondyle fractures are treated nonoperatively, with early
ROM. Fragment displacement >1 cm or valgus instability is generally
treated by internal fixation. ED treatment consists of long arm
posterior mold immobilization,
with the forearm in flexion and pronation and the wrists in flexion,
and orthopedic referral.
Complications of lateral and medial epicondyle fractures are
frequent and include nonunion, cubitus valgus or varus deformity,
ulnar nerve palsy, and avascular necrosis.18 Careful
neurovascular assessment is required for these injuries. Because
surgical treatment is generally preferred, emergent orthopedic consultation
is recommended for both lateral and medial epicondyle fractures.
Lateral condyle fractures occur in children and are more common
than their medial counterpart.19 Lateral condyle
fractures result from a direct blow to the lateral elbow or from
varus stress with the forearm extended, as in a fall on an outstretched
hand. Patients complain of pain in the lateral elbow, and swelling
is noted in the same area.
Medial condyle fractures are uncommon and are mostly limited
to children. Mechanism of injury is from either a transmitted force
from the ulna, such as a fall on an outstretched hand, or excessive
valgus stress. Pain and swelling medially are prominent findings.
The injury is often confused with the more common medial epicondyle
fracture for two reasons. First, the mechanism and examination findings
are similar. Second, because the trochlea ossification center does
not appear until age 9 to 10 years old, it is often missed on radiographs.
ED care of nondisplaced lateral and medial condyle fractures
with normal neurovascular function includes long arm posterior mold
immobilization, ice, elevation, analgesics, and orthopedic referral.
Displaced fractures or those with neurovascular compromise require
immediate orthopedic consultation.
Isolated trochlea fractures are rare, and they are more often
associated with other elbow injuries, such as posterior elbow dislocations.
Physical findings usually include swelling, tenderness, and limited
movement of the elbow joint. Radiographic findings can be subtle,
and US or MRI may be required for diagnosis. ED treatment includes
long arm posterior mold immobilization and orthopedic consultation,
as this is an articular surface injury and surgical repair is usually
indicated. Complications are common and include limited flexion
and extension, elbow joint instability, avascular necrosis, nonunion, and
Isolated capitellum fractures are rare. They are usually associated
with radial head fractures. Pain and tenderness are present over
the lateral elbow, and examination reveals swelling, lateral tenderness,
and limitation of flexion and extension. If pain and tenderness
are present medially, injury to the medial collateral ligament should be
suspected. Radiographic findings may be subtle and are best seen
on a lateral view. The capitellum has no tendinous or ligamentous
attachments, so many fractures are nondisplaced. A radial head-capitellum view
can be helpful in addition to standard views. ED treatment is similar to
that of trochlea fractures. Definitive care is surgical and complications are
similar to those of trochlea fractures.
The distal humerus articulates with the proximal ulna to form
a uniaxial hinge joint, which allows flexion and extension of the
forearm and provides some intrinsic stability. The trochlea of the
humerus rests in the greater sigmoid (semilunar) notch of the ulna. The
anterior projection of the notch is the coronoid, and the posterior prominence,
which is easily palpable, is the olecranon. The brachialis muscle
inserts at the coronoid, and the triceps muscle inserts at the olecranon.
Nearly all proximal ulna fractures are considered intra-articular, with
the exception of a proximal olecranon chip fracture.
Coronoid fractures are uncommon and usually associated with posterior elbow
dislocations as the trochlea is driven into the coronoid, or as
an isolated injury secondary to elbow hyperextension. There is pain,
swelling, and tenderness over the antecubital fossa. Radiographic
visualization is best with lateral and oblique films. Often CT is
needed to make the diagnosis. Coronoid fractures can be classified
into three types (Table 267-2.1).20
Table 267-2.1 Classification of Coronoid Fractures |Favorite Table|Download (.pdf)
Table 267-2.1 Classification of Coronoid Fractures
|Type I||Anterior tip of coronoid|
|Type II||Up to 50% of the height of the coronoid|
|Type III||The base of the coronoid|
ED treatment should include long arm posterior mold immobilization with
the elbow in flexion and the forearm in supination, ice, elevation, analgesics,
and referral to an orthopedic surgeon within 24 hours. Type II and
III fractures or those associated with joint instability require
open reduction and internal fixation, and frequently have poor outcomes.
The olecranon is usually fractured by direct trauma or by a fall
with forced hyperextension of the elbow. They are quite common and
represent up to 10% of upper extremity fractures.21 The
Mayo classification is used to identify the severity of these fractures (Table 267-2.2). Associated injuries are common,
including open fractures, dislocations, other fractures (especially
of the radial head), and ulnar nerve injury. Pain is present over
the posterior elbow, and examination reveals swelling, tenderness,
and occasionally crepitus. Because the triceps muscle inserts at the
olecranon, triceps function is usually compromised when tested by forearm
extension. Ulnar nerve injury is common, and, therefore, a careful
neurologic examination is required. Lateral radiographs offer the
best view of the olecranon. In adolescents, the epiphysis ossifies
by age 11 years old and fuses by age 16 years old, so comparison
films and the appearance of an abnormal fat pad can aid in the diagnosis.
ED treatment includes long arm posterior mold immobilization with
the elbow in flexion and forearm neutral, ice, elevation, analgesics,
and referral to an orthopedist within 24 hours. Type I fractures
can be treated conservatively with immobilization, but all others
require surgical repair.
Table 267-2.2 Mayo Classification of Olecranon Fractures |Favorite Table|Download (.pdf)
Table 267-2.2 Mayo Classification of Olecranon Fractures
|Type I||Nondisplaced, stable fracture|
|Type II||Displaced, stable joint|
|Type III||Displaced, unstable ulnohumeral joint|
The radial head is located just distal to the lateral epicondyle.
Pronating and supinating the forearm with the elbow flexed allows
the examiner to palpate the radial head. It articulates with the
capitellum and the lesser sigmoid notch of the ulna to form a pivot
joint. The radial head serves as a stabilizer of the elbow against
valgus stress, along with the medial collateral ligament, and against
Radial head fractures are the most common fractures of
the elbow. They result from a fall on an outstretched hand
causing the radial head to be driven into the capitellum. Associated
injuries are common and may include capitellum, olecranon, and coronoid
fractures, medial collateral ligament injury, medial epicondyle
avulsion fracture secondary to valgus stress, and elbow dislocation. A
specific associated injury, the Essex-Lopresti lesion, occurs when
there is disruption of the triangular fibrocartilage of the wrist
and the interosseous membrane between the radius and ulna, causing
pain in the wrist and forearm. The result is a distal radioulnar
joint dissociation, which can cause migration of the radius proximally
if radial head excision is performed.
Radial head fractures cause pain in the lateral
elbow, especially with pronation and supination of the forearm.
On examination, there may be swelling laterally and tenderness with
palpation of the radial head. On standard elbow radiographs, radial
head fractures may be subtle (Figure 267-11).
Additional images, including obliques
and a radial head-capitellum view, may be helpful. Furthermore,
two radiographic clues can aid in the diagnosis. The first is the
radiocapitellar line. On lateral films, a line drawn from the center
of the radial shaft should transect the radial head and capitellum
(Figure 267-12). This is especially helpful
in children whose epiphysis has not fused. The other clue is the
appearance of an abnormal fat pad (Figure 267-8).
Subtle radial head fracture and anterior fat pad sign (arrow).
The radiocapitellar line. On lateral views, a line drawn through
the center of the radius transects the radial head and middle third
of the capitellum. This relationship is lost even in subtle fractures.
Nondisplaced fractures with no mobility restrictions can be treated
conservatively with immobilization. For these, ED treatment consists
of sling immobilization with the elbow in flexion, ice, elevation,
analgesics, and referral to an orthopedic surgeon within 1 week.
For displaced fractures or those with restricted ROM, surgical repair
is generally indicated, and orthopedic referral within 24 hours
is needed. Complications of radial head fracture include chronic
pain and restricted ROM at the elbow.