Continuing Education Activity

Elbow trauma is a common occurrence in children and athletes and can cause a broad array of injury patterns ranging from mild soft tissue injuries and contusions to complex osteoligamentous injuries. Interprofessional team members must be familiar with elbow anatomy since elbow trauma puts a large number of neurovascular structures at risk. Thorough examination and workup of elbow trauma will allow for proper management, which will lead to better patient outcomes. This activity reviews the evaluation and management of elbow trauma injuries and highlights the role of the interprofessional team in caring for affected patients.

Objectives:

• Review the etiology of elbow trauma.
• Describe the common presentation of a patient with elbow trauma.
• Identify management options for patients with elbow trauma.
• Explain the importance of improving care coordination amongst the interprofessional team to optimize outcomes for patients with elbow trauma.

Introduction

Elbow trauma is a common entity in the acute care setting.  In general, these injuries encompass a vast array of injury patterns from mild soft tissue injuries and contusions to complex osseoligamentous injury patterns and terrible triad injuries.  In the adult patient, most of these acute injuries occur secondary to high energy mechanisms such as falls from height or motor vehicle accidents (MVAs).[1]  Elderly patients, however, are at risk for elbow injuries and traumatic fractures following even low-energy falls.  The latter occurs secondary to a multitude of factors, including deconditioning, decreased agility and balance, poor vision, decreased muscle mass, and osteopenia or osteoporosis.[2][3][4][5]

Anatomy overview

The elbow joint is one of the most complex joints in the human body, comprised of three distinct articulations: ulnohumeral, radiohumeral, and proximal radioulnar joints.[6]  The anterior aspect of the proximal ulna (i.e., the trochlear notch or semilunar notch) articulates with the trochlea of the distal humerus on the medial side of the elbow joint. The capitellum, a distinct ossification center located at the lateral distal humerus, articulates with the radial head.[7]

The radial neck and the proximal radial metaphyseal region includes the radial tuberosity, the site of attachment of the distal biceps tendon.[8]  The ulnar collateral ligament (UCL) and lateral collateral ligament (LCL) complex play an important role in stabilizing the joint to valgus and varus stress throughout the arc of motion, respectively.  Moreover, these ligamentous structures contribute to the physiologic rotational stability of the elbow joint. The transition between the upper arm and the forearm is the region of the antecubital fossa, which contains the radial nerve, brachial artery, and median nerve.[9][10][11]

Etiology

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

• Traumatic injuries
  • Soft tissue injuries range from mild, superficial soft tissue injuries (e.g., simple contusions, strains, or sprains) to traumatic arthrotomies following gunshot wounds or penetrating lacerations
  • The osseoligamentous spectrum of injury encompasses fractures, fracture-dislocations, ligamentous injuries, and simple versus complex dislocation patterns
    • "Simple" referring to no associated fracture accompanying the dislocation
    • "Complex" refers to an associated fracture accompanying the dislocation
  • Terrible triad elbow injuries
    • Elbow dislocation
      • Typically posterolateral direction with associated LCL complex injury
      • Elbow dislocation is the two most common dislocated joint after the shoulder - most are posterior dislocations
    • A radial head/neck fracture
    • Coronoid fracture
• Attritional injuries
  • Encompasses subacute or chronic presentations following various repetitive motion mechanisms
    • Often seen in athletes involved in any upper extremity sport-related activity requiring repetitive motions (e.g., overhead throwers/baseball pitchers, tennis)
    • Manual laborers with analogous occupational repetitive demands

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.  Direct trauma to the elbow, which often occurs from a fall directly onto the olecranon can yield various types of fracture- and fracture-dislocation patterns as well.  Additionally, isolated soft tissue injuries can range from mild contusions, sprains, and strains to more significant soft tissue-based injuries requiring clinical attention, such as deep penetrating lacerations or gunshot wounds (GSWs) resulting in traumatic arthrotomies.  While simple elbow dislocations most often resolve following nonoperative management alone, some patients develop recurrent dislocations or subluxation episodes.  These patients present commonly present with painful clicking and weakness.[12]

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.[13][14]

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)[11]:

• Supracondylar fractures
  • Most common in childrenpeak ages 5 to 10 years, rarely occurs at greater than 15 yearsExtension type (98%): fall on an outstretched hand with fully extended or hyperextended armType 1: minimal or no displacementType 2: slightly displaced fracture, posterior cortex intactType 3: totally displaced fracture, posterior cortex brokenFlexion type: blow directly to a flexed elbowType 1: minimal or no displacementType 2: slightly displaced fracture, anterior cortex intactType 3: totally displaced fracture, anterior cortex broken
• Lateral condyle fractures
• Medial epicondyle fractures
• Radial head and neck fractures
  • Usually indirect mechanism (such as fall on an outstretched hand), and the radial head being driven into capitellum
• Olecranon fractures

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

Epidemiology

Elbow trauma in the young adult usually occur in the setting of sports and following either an acute avulsion injury, ligamentous injury, or insidiously and progressively with chronic repetitive trauma. Weight lifters often sustain sprains and strains injury to the elbow, accounting for 2.6% of all bodily sprains and strains.[15][16] Sports that commonly associated with elbow trauma are those with high impact (skateboarding, inline-skating, skiing) and those involved in overarm-throwing sports such as cricket, baseball, and tennis. Overarm-throwing sports usually associated with elbow collateral ligament insufficiency.[17]

Pediatric considerations

The epidemiology of elbow trauma in children is interesting due to a trend toward earlier physical fusion in girls compared to boys. In girls, most physical fractures occur at the ages of 9mto 12 and 12 to 15 years in boys. The boy-to-girl ratio for the incidence of physical fractures when examined for specific ages varied from 1 to 1 in children 11 years old or younger and 7 to 1 in children older than 11 years.[11] About 15% of all pediatric fractures are epicondylar fractures, and the peak incidence of age is around 6 years of age.[18] Elbow dislocation in children is not as common as fracture; it accounts 3 to 5% of all pediatric elbow injuries; mostly the posterolateral type. Peak incidence occurs during adolescence, ages 12 to 13 years.[11][19]

History and Physical

Patients will present acutely with varying degrees of swelling and deformity.  Pain and limited range of motion (ROM) are the expected presentation.  A comprehensive physical examination includes examination from the shoulder to the hand of the ipsilateral extremity in question.  Case reports in the literature highlight the not uncommon presentation of some combination of the forearm, elbow, and humeral-based fractures.  One such report included the presence of an ipsilateral elbow dislocation, humeral shaft fracture, and shoulder dislocation following high energy trauma.[20]  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

Beside acute compartment syndrome, chronic compartment syndrome may develop. Symptoms of chronic compartment syndrome include worsening pain or cramping in the affected muscle within a half-hour of starting an exercise. Symptoms typically go away with rest, and muscle function remains normal.

Clinical features of acute compartment syndrome (ACS)

The initial suspicion of a diagnosis of ACS is mainly clinical. There are some classic features, including pain, pallor, pulselessness, pressure, paraesthesia, poikilothermia, and paralysis. If the patient has all the features, this could indicate a late diagnosis and irreversible damage because some features such as paralysis occur very late in the pathogenesis of ACS. Therefore, it is highly suggested to do a serial assessment to detect a more catastrophic clinical state rather than at one point in time.

Research has taken on the predictive values of the cardinal features. To calculate the predictive value, Bayes used the following features of ACS: pain, paraesthesia, paresis, and pain on passive movement. All features were more specific than they were sensitive: mean specificity is 0.97 (range 0.97 to 0.98) and mean sensitivity 0.16 (range 0.13 to 0.19). The positive predictive values ranged from 0.11 to 0.15, and all negative predictive values were 0.98. The low positive predictive value suggests that these symptoms on their own are poor indicators of ACS.[21][22]

Once ACS is suspected, definitive diagnosis involves obtaining the intracompartmental pressure. The assessment could be with direct, invasive monitoring. When obtaining intracompartmental pressures, a catheter is placed within 5 cm of the fracture level, with the transducer secured at the level of the measured compartment. It is important to keep the catheter tip outside of the actual fracture site. If placed within the fracture, levels will be falsely high. Failure to place the transducer at the same height of the catheter tip will cause a falsely high or low, depending upon the position. When the first pressure is normal, but ACS is suspected, a compartment recheck is needed, with another pressure assessment.[23]

Although beyond the scope of this review, heightened suspicion is appropriate during the assessment of pediatric patients and infants.  Due diligence should be performed to rule out child abuse when applicable.[11][24]

Evaluation

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.
• Nurse elbow can reduce spontaneously when the patient supinates the arm. 

Advanced imaging sequences[11][24][18]

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.

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

Treatment / Management

In general, mild soft tissue injuries are manageable with rest, ice, NSAIDs, and early range of motion.  The pitfall in managing elbow injuries lies in the fact that the joint gets stiff quickly and depending on patient characteristics, formal physical therapy may be recommended to ensure an overall functional outcome.  

The management of elbow trauma and fractures is beyond the scope of this review.  However, most fracture patterns with displacement require surgical management with open reduction internal fixation (ORIF) performed, followed by formal physical therapy postoperatively.  Simple elbow dislocations (i.e., no associated fracture) almost all can be managed with closed reduction and sling immobilization for 10 to 14 days followed by early ROM.  The examiner should take advantage of the initial post-reduction examination, including documented ROM and neurovascular status upon successful reduction of the joint.  Performing this examination in the acute setting can help guide not only the duration of joint immobilization in a sling, but the possibility of developing posterolateral rotatory instability (PLRI) that can present chronically with painful clicking, weakness, and feelings of instability with various activity.  These patients require operative intervention to mitigate the risk of a poor outcome.

Nondisplaced fractures can be treated with a splint initially, and in general, greater than 2mm of displacement in most fracture patterns require referral for operative consideration.

Uncomplicated posterolateral dislocation usually treated with closed reduction. If there is evidence of entrapped medial epicondylar fragment, open reduction may be needed.[11][19]

Emergency department treatment and procedures

• Orthopedic consultation is the standard for all but nondisplaced, stable fractures, which as a rule, can be splinted 24 to 48 hours orthopedic follow-up
• Fractures generally requiring orthopedic consultation:
  • Transcondylar, intercondylar, condylar, epicondylar fractures
  • Fractures involving articular surfaces such as capitellum or trochlea
• Supracondylar fractures:
  • ED physician can handle type 1 with 24 to 48 hours orthopedic follow-up
  • The elbow may be flexed and splinted with a posterior splint
  • Types 2 and 3 require an immediate orthopedic consult
  • Reduce these in ED when the fracture is associated with vascular compromise
• Anterior dislocation:
  • Reduce immediately if vascular structures compromised
  • Then flexed to 90º and place the posterior splint
• Posterior dislocation:
  • Reduce immediately if vascular structures compromised
  • Then flexed 90º and place posterior splint.
• Radial head fracture:
  • Minimally displaced fractures may need aspiration to remove hemarthrosis: instill bupivacaine and immobilize.
  • Other types should have an orthopedic consult.
• Radial head subluxation
  • In one continuous motion, supinate and flex elbow while placing slight pressure on the radial head.
  • Hyperpronation technique is possibly more effective - while grasping the patient’s elbow, the wrist is hyper-pronated until feeling a palpable click.
  • A palpable click will often accompany the reduction
  • If the exam suggests fracture, but radiograph is negative, splint and have the patient follow up in 24 to 48 hours for re-evaluation

Medication

• Conscious sedation is often necessary to achieve reductions
• Ibuprofen: 600 to 800 mg (pediatric: 5 to 10 mg/kg) PO TID
• Naprosyn: 250 to 500 mg (pediatric: 10 to 20 mg/kg) PO BID
• Tylenol with codeine: 1 or 2 tabs (pediatric 0.5 to 1 mg/kg codeine) PO: do not exceed acetaminophen 4g/24 hours
• Morphine sulfate: 0.1 mg/kg IV 
• Hydromorphone 5 mg/acetaminophen 300mg
• Hydrocodone/acetaminophen: 1 to 2 tabs PO

Attritional injuries management modalities

Treatment for repetitive trauma such as lateral epicondylitis or tendinitis, demonstrate successful outcomes with nonoperative management modalities alone.  These include but are not limited to[25][26][17]:

• Rest, ice, and NSAIDs
• Physical therapy when appropriate
  • Eccentric exercises for lateral epicondylitis
• Corticosteroid injection when applicable
• Platelet-rich plasma (PRP) considerations
  • 2016 study noted efficacy in managing UCL insufficiency

Disposition

• Admission Criteria
  • Vascular injuries, open fracture
  • 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 the 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 to 48 hours
  • Uncomplicated soft tissue injuries.

It is crucial to recall that prolong elbow immobilization can cause stiffness to the patient, so the main goal is to get the elbow's range of movement back as soon as possible.

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

Prognosis

The treated fracture usually have a good prognosis. Some patients may demonstrate loss of terminal extension about 10 to 15 degrees, but this is not clinically significant. Dislocation can cause compression of nerve or vascular, and early management of this condition will minimize the complication. Bursitis patients also have a good prognosis. For infectious bursitis, a systemic infection may happen but at very low risk.[11][24][27][28]

Complications

The most common complications include neurovascular complications following fracture and dislocation. Transient ulnar neuropathy incidence is 10%. Another less common complication is median nerve entrapment. Vascular complication such as reduction or obliteration of the radial pulse may occur. Prolonged immobilization of elbow can cause stiffness and terminal extension loss, which can be problematic, especially in children and athletes.[11][24] 

Deterrence and Patient Education

Patients are encouraged to follow instructions and post-injury or post-operative rehabilitation protocols as dictating by his or her provider(s).  Also, in complex elbow injury patterns and traumatic fracture-dislocations (i.e., terrible triad elbow injuries), it is important to manage patients expectations appropriately.  Nearly all patients experience some degree of post-recovery loss of ROM.  Thus, it is important to emphasize regaining elbow ROM following any elbow injury.

Enhancing Healthcare Team Outcomes

A thorough evaluation of elbow trauma by the primary care provider, nurse practitioner, and the emergency department physician is vital for optimal patient outcomes. Radiographic evaluation of elbow trauma is an essential tool in the acute setting, and a firm understanding of anatomy, radiographic landmarks, and common injury is necessary. For chronic elbow overuse injury, radiography, and MRI are vital tools for diagnostic. Making the right diagnosis and not delaying treatment can reduce unwanted complication. 

Elbow trauma management requires an interprofessional team approach, including physicians, specialists, specialty-trained nurses, physical therapists, and pharmacists, all collaborating across disciplines to achieve optimal patient results. [Level V]