All fractures of the olecranon should be considered intra-articular (Fig. 14–12). It is essential that near-perfect anatomic reduction be achieved to ensure full range of motion.
Olecranon fractures are usually the result of one of two mechanisms. A fall or direct blow to the olecranon may result in a comminuted fracture. The amount of triceps tone and the integrity of the triceps aponeurosis determine if the fracture will be displaced.
Indirectly, a fall on the outstretched hand with the elbow flexed and the triceps contracted may result in a transverse or oblique fracture. The amount of displacement is contingent on the tone of the triceps, the integrity of the triceps aponeurosis, and the integrity of the periosteum.
Axiom: All displaced olecranon fractures have either a rupture of the triceps aponeurosis or the periosteum.
The patient will present with a painful swelling over the olecranon and a hemorrhagic effusion. The patient will be unable to actively extend the forearm against gravity or resistance due to the inadequacy of the triceps mechanism. It is not uncommon for comminuted fractures to result in compromise of ulnar nerve function. It is of critical importance that the initial examination includes documentation of ulnar nerve function.
Radiographically, a lateral view with the elbow in 90 degrees of flexion is best for demonstrating olecranon fractures and displacement (Fig. 14–13). Absence of displacement on extension views is not considered definite proof of a nondisplaced fracture, as the fragments may displace only with elbow flexion. Separation of the fragments or articular incongruity by more than 2 mm is considered sufficient to classify the fracture as displaced.6
Olecranon fractures. A. Nondisplaced. B. Displaced. Any fracture with >2 mm of separation should be considered displaced and will require surgery.
In children, the olecranon epiphysis ossifies at 10 years of age, and fuses by the age of 16. Interpretation of fractures in children may be difficult, and comparison views should be used whenever doubt exists. In addition, the presence of a posterior fat pad or a bulging anterior fat pad should be regarded as indicative of a fracture.
Olecranon fractures are frequently associated with ulnar nerve injury; elbow dislocation; anterior dislocation of the radioulnar joint; or concomitant fractures of the radial head, radial shaft, and distal humerus.
Fractures with <2 mm of separation or articular incongruity are considered nondisplaced. Treatment begins with immobilization in a long-arm splint (Appendix A–9) with the elbow flexed only 50 to 90 degrees and the forearm in a neutral position.7,8 This position decreases the pull from the triceps muscle. A cast is used for definitive management, and should be well molded posteriorly and supported with a collar and cuff. Finger and shoulder range of motion exercises should be started as soon as possible, with repeat radiographs obtained in 5 to 7 days to exclude displacement. Union is complete in 6 to 8 weeks, but the cast may be removed by the orthopedist as early as 1 week in adults to avoid chronic stiffness.
An alternate program used by some orthopedists in stable fractures is to apply a posterior long-arm splint with the elbow in 90 degrees of flexion (Appendix A–9) and not proceed to casting. Supination and pronation exercises can be initiated in 3 to 5 days, with flexion–extension exercises at 1 to 2 weeks. The protective splint is used until healing is complete (usually 6 weeks).
Initial emergency department (ED) management includes splinting in 50 to 90 degrees of flexion with the administration of ice, analgesics, and elevation. Because olecranon fractures are intra-articular, they necessitate anatomic reduction through operative fixation. Displaced fractures of the olecranon include those with displacement of a transverse fracture, a comminuted fracture, an avulsion fracture, or an epiphyseal fracture. These fractures are intra-articular and necessitate anatomic reduction through operative fixation. Therefore, emergent orthopedic referral is indicated.
The most common complication is the development of shoulder arthritis and inhibition of shoulder mobility. There is a small incidence (5%) of nonunion.
Radial Head and Neck Fractures
Radial head and neck fractures are relatively common in adults, accounting for one-third of all elbow fractures (Fig. 14–14).9 Smooth motion of the radial head is essential for full and painless pronation and supination. With fragmentation or displacement, arthritis with restricted motion may result. Therapeutic programs must focus on the restoration and retention of full motion. The classification system that follows is therapeutically oriented. Radial head and neck fractures are divided into three groups: (1) marginal (intra-articular) fractures, (2) neck fractures, and (3) comminuted fractures. In general, nondisplaced fractures are treated closed (at least initially), whereas in most cases displaced fractures require open reduction. There is some controversy in the management of these fractures, particularly in the postinjury mobilization phase. As in previous chapters, we will make every effort to present both positions where legitimate controversy exists.
Radial head and neck fractures. A. Marginal fractures. B. Neck fractures. C. Comminuted fractures.
The most common mechanism is a fall on the outstretched hand (indirect). With the elbow in extension the force drives the radius against the capitellum, resulting in a marginal or radial neck fracture (Fig. 14–15). As the force increases, comminution, dislocation, or displaced fragments occur. The fracture pattern in adults and children is variable, due to differences in the strength of the proximal radius. In adults, marginal or comminuted fractures of the radial head or neck with articular involvement are common. In children, displacement of the radial epiphysis is common, whereas articular involvement is rare.
Radial head fracture secondary to a fall on an outstretched arm.
Tenderness will be present over the radial head with swelling secondary to a hemarthrosis. Pain is exacerbated by supination and associated with reduced mobility. Children with epiphyseal injuries may have very little swelling, but pain will be elicited with palpation or motion. If the patient has associated wrist pain, disruption of the distal radioulnar joint should be suspected, and urgent orthopedic referral is recommended.
Axiom: Wrist pain associated with a fracture of the radial head suggests disruption of the distal radioulnar joint and the radioulnar interosseous membrane (Essex-Lopresti fracture dislocation).
Visualization of radial head and neck fractures often requires oblique views (Figs. 14–16 and 14–17). Impact fractures of the neck are best seen on the lateral projection. If a radial head fracture is suspected, but not seen, additional views in varying degrees of radial rotation should be obtained. An enlarged anterior fat pad or the presence of a posterior fat pad suggests a joint effusion and strongly suggests an occult fracture, most commonly of the radial head. In addition, the radiocapitellar line should be evaluated in attempting to diagnose pediatric epiphyseal fractures or radial head dislocations.
A displaced marginal fracture of the radial head.
Displaced comminuted fractures of the radial head and neck.
Fracture of the capitellum should be suspected in all proximal radius fractures. This structure must be closely examined, looking for any evidence of fracture.
A valgus strain often results in medial collateral ligament sprain or rupture. In addition, avulsion of the medial epicondyle is frequently seen in both children and adults.
Disruption of the interosseous membrane between the radius and ulna and injury to the distal radioulnar joint ligaments may also occur. An Essex-Lopresti injury should be recognized early as internal fixation is often indicated.
For further discussion of epiphyseal fractures, the reader is referred to Chapter 6. In general, radial head epiphyseal fractures with angulation of <15 degrees are best treated with immobilization for 2 weeks in a long-arm posterior splint (Appendix A–9) followed by a sling. Remodeling will generally correct this degree of angulation. With >15 degrees, an orthopedic surgeon should be consulted because reduction is required. Angulation >60 degrees often requires open reduction.
The remainder of the discussion regarding the treatment of radial head and neck fractures applies to adults.
Marginal radial head fractures with displacement of <2 mm (marginal fractures or minimal depression fractures) are treated with a sling or a long-arm posterior splint (Appendix A–9). If splinted, the splint should remain in place for no more than 3 to 4 days. Early motion exercises are recommended if they can be tolerated (pain).
When there is displacement or depression of >2 mm with over one-third of the articular surface involved, operative treatment is required. The initial ED management includes aspiration of the hematoma for pain relief and a long-arm posterior splint with the elbow in 90 degrees of flexion and the forearm neutral (Appendix A–9). Displaced fractures with less than one-third of the articular surface involved are reduced and followed by early motion.
Early referral is indicated for all of these fractures. Surgical excision of displaced radial head fractures is no longer recommended in young active patients. Better operative techniques and implant placement often make radial head repair the treatment of choice.10
Neck fractures without displacement and angulation of <30 degrees are treated with immobilization in a sling or a long-arm posterior splint and urgent orthopedic referral (Appendix A–9). Definitive therapy is controversial.11
These patients should be placed in a long-arm posterior splint (Appendix A–9). With angulation >30 degrees or significant displacement, operative fixation is recommended.
These fractures can be treated conservatively with a long-arm posterior splint (Appendix A–9). Early motion exercises are recommended.
These patients should be placed in a long-arm posterior splint (Appendix A–9). With severe comminution of the head, excision of fragments or a prosthetic head replacement is the recommended therapy.10–13
In addition to the treatments outlined in this section, early aspiration of the joint should be considered for radial head and neck fractures, as this serves to reduce pain and facilitate early mobilization. This technique is as follows:
The skin of the lateral elbow should be prepped using sterile technique.
An imaginary triangle should be constructed over the lateral elbow connecting the radial head, the lateral epicondyle, and the olecranon (Fig. 14–18). Only skin and the anconeus muscle cover the joint capsule in this area, and there are no significant neurovascular structures in the area.
The skin should be anesthetized with lidocaine.
Using a 20-mL syringe and an 18-gauge needle, the joint capsule is penetrated by directing the needle medially and perpendicularly to the skin. When the capsule is entered, blood is aspirated (usually 2–4 mL).
The safest place to aspirate the elbow is in the center of a triangle produced by connecting the lateral epicondyle of the humerus, the olecranon, and the radial head. Aspiration should be performed by inserting the needle through the center of this triangle.
Coronoid Process Fractures
Coronoid process fractures are classified as (1) nondisplaced, (2) displaced, and (3) displaced with posterior elbow dislocation (Fig. 14–19). These fractures are rarely seen as isolated injuries and are noted more commonly with posterior dislocations of the elbow.14
Coronoid process fractures. A. Nondisplaced. B. Displaced. C. Posterior dislocation.
Isolated coronoid process fractures are thought to be due to hyperextension with joint capsule tension and subsequent avulsion. When coronoid fractures are associated with posterior dislocations, the mechanism is a “push-off” injury by the distal humerus.
Tenderness and swelling over the antecubital fossa is noted frequently.
The coronoid fragment is best visualized on a lateral radiograph, although oblique views may be necessary. The fragment may be displaced, as with an avulsion fracture, or impacted against the trochlea, as is frequently noted with fracture dislocations. Nondisplaced coronoid fractures may be missed on radiographs and computed tomography (CT) or MRI should be considered to rule out small fractures.15
This fracture is commonly associated with elbow dislocations, and a more detailed discussion of treatment can be found in that section of this chapter.
Isolated nondisplaced fractures are treated with a long-arm posterior splint (Appendix A–9). The elbow should be in over 90 degrees of flexion and the forearm in supination. This should be followed by active exercises with sling support. The treatment of these fractures is controversial and early referral is strongly urged.
Displaced fractures require emergent orthopedic referral, especially if they are greater than 50% of the size of the coronoid process or the elbow joint is unstable. In both cases, fragment fixation is recommended. If the fracture fragment is small, treatment in a long-arm posterior splint (Appendix A–9), as for nondisplaced coronoid fractures, is appropriate. Small, displaced fracture fragments are managed nonoperatively.7
Displaced with Posterior Dislocation
Fracture dislocations will be discussed under the section “Elbow Dislocations” later in the chapter. Reduction of the dislocation will frequently result in coronoid fracture reduction.
Coronoid process fractures are infrequently associated with the development of osteoarthritis.
A supracondylar fracture is a transverse fracture of the distal humerus above the joint capsule, in which the diaphysis of the humerus dissociates from the condyles. In children, approximately 60% of all elbow fractures are supracondylar.16,17 The incidence is highest between the ages of 3 and 11. They occur more frequently in children because the surrounding ligaments are stronger than the bone. As ligament laxity increases with age, ligament tears without fracture are more common in adults. Distal humerus fractures comprise only 0.5% of all fractures in adults and are most common in osteopenic adults over the age of 50. In the older age group, these fractures are often comminuted. Supracondylar fractures are covered in further detail in Chapter 6.
Supracondylar fractures are subdivided based on the position of the distal humeral segment into (1) extension-type (posterior angulation or displacement) or (2) flexion-type (anterior angulation or displacement) fractures (Fig. 14–20). The vast majority (95%) of displaced supracondylar fractures are of the extension type.17
Supracondylar fractures. A. Extension type. B. Flexion type.
The most common classification used for extension supracondylar fractures was proposed by Gartland in 1959, who divided them into three types. Type I fractures are nondisplaced. Type II fractures are displaced, but the bony fragments are still partially apposed. Type II fractures were subsequently divided into type IIA (angulated extension fracture with an intact posterior cortex) and type IIB (displaced fracture with partial posterior translation) injuries.17 Type III fractures include those with complete displacement of the fracture fragments. The diagnosis and management of these fractures varies, depending on the type of fracture that exists.
Two mechanisms result in fractures of the distal humerus. With the elbow in flexion, a direct blow can result in a fracture. The position of the fragments is dependent on the magnitude and direction of force as well as the initial position of the elbow and the forearm (e.g., flexion and supination) along with the muscular tone.
The indirect mechanism involves a fall on the outstretched hand (Fig. 14–21). As before, the magnitude and direction of force, as well as the position of the elbow and the muscular tone, determine the position of the fracture fragments. Over 90% of supracondylar fractures result from the indirect mechanism. Typically, the fracture is an extension fracture, where the distal fragment is displaced posteriorly.
The indirect mechanism of producing a supracondylar fracture involves a fall on the outstretched hand.
Flexion fractures, where the distal humeral fragment is displaced anteriorly, account for only 10%. They are usually the result of a direct blow against the posterior aspect of the flexed elbow (Fig. 14–22). The indirect mechanism uncommonly results in a flexion fracture.
With the elbow in flexion a direct blow to the olecranon can result in a distal humeral fracture.
The emergency physician must complete a careful physical examination, with special attention to the brachial, radial, and ulnar pulses along with the median, radial, and ulnar nerves. Comparison with the uninjured extremity should be a routine part of each examination. Frequently, supracondylar fractures are associated with extensive hemorrhage and swelling, which, in some instances, may result in compartment syndrome.
Recent injuries may demonstrate little swelling with severe pain. The displaced distal humeral fragment can often be palpated posteriorly and superiorly because of the pull of the triceps muscle. As swelling increases, extension supracondylar fractures can be confused with a posterior dislocation of the elbow resulting from the prominence of the olecranon and the presence of a posterior concavity (Fig. 14–23). In addition, the involved forearm may appear shorter when compared with the uninvolved side. In patients with flexion supracondylar fractures, the elbow is usually carried in flexion, and there is a loss of the olecranon prominence.
Clinical picture of a child with a displaced supracondylar fracture. (From Sherman SC. Supracondylar fractures. J Emerg Med. 2011;40(2):e35–e37. With permission from Elsevier Scientific Publications.).
The initial radiographic examination should include AP and lateral views (Fig. 14–24). On the AP film, the forearm should be supinated and the elbow placed in as much extension as possible. The lateral film should be taken with the elbow in 90 degrees of flexion. Additional oblique views with the elbow in extension may be helpful in diagnosing occult fractures.
Radiograph of the same child in Fig. 14–23 confirms a type III (complete displacement) supracondylar fracture. (From Sherman SC. Supracondylar fractures. J Emerg Med. 2011;40(2):e35–e37. With permission from Elsevier Scientific Publications.)
The distal segment may be displaced, angulated, or rotated with respect to the proximal bone, resulting in various deformities. Approximately 25% of supracondylar fractures are nondisplaced. Radiographic diagnosis in these cases may be exceedingly difficult. Subtle changes, such as the presence of a posterior fat pad, an abnormal anterior humeral line, or an abnormal carrying angle may be the only radiographic clues to the presence of a fracture.
Supracondylar fractures are frequently associated with neurovascular complications, especially in the presence of displacement.
The extremity of all patients with supracondylar fractures should be assessed for pulses, color, temperature, and capillary refill. Type III supracondylar fractures present with vascular compromise in approximately 5% to 10% of cases due to impingement by fracture fragments, swelling, or arterial laceration. Document the presence and strength of the radial, ulnar, and brachial pulses. Absent pulses with adequate perfusion is well documented in displaced supracondylar fractures and is made possible by good collateral circulation. Management of a pulseless, well-perfused extremity following adequate reduction varies from observation to operative exploration. Arteriography is not usually necessary.
In patients with intact pulses, a pulse oximeter can be applied to monitor the pulse rate as well as the hemoglobin saturation. The presence of a pulse, however, does not exclude a significant arterial injury.
Function of the radial, median, and ulnar nerves should be tested as deficits can occur with displaced supracondylar fractures. The incidence of nerve injury following type III fractures is 10% to 15%. In those fractures that are posteromedially displaced, neural compromise is more likely to occur.18 These injuries are common because the nerves are tethered at the elbow and displacement leads to stretching.
The most common nerve injury is to the anterior interosseous nerve. This nerve does not have sensory innervations and when a deficit is present, only subtle motor findings are seen, making this injury easily missed. The anterior interosseous nerve innervates the flexor digitorum profundus of the index finger (flexion of DIP joint) and the flexor pollicis longus (flexion of IP joint). A deficit is detected by having the patient make an “OK” sign and noting weakened flexion at these two joints. Testing nerve function is important because iatrogenic injuries can occur after multiple attempts at closed reduction or following operative repair. Most nerve injuries are neuropraxias, and function returns without interventions over the course of 3 to 6 months.
Extension Supracondylar Fracture
Type I. Supracondylar fractures that are not displaced or angulated are immobilized in a posterior long-arm splint, extending from the axilla to a point just proximal to the metacarpal heads (Appendix A–9). The splint should encircle approximately three-fourths of the circumference of the extremity. The forearm is kept in a neutral position and the elbow is flexed from 80 to 90 degrees. The distal pulses should be checked and, if absent, the elbow is extended 5 to 15 degrees or until the pulses return. A sling is used for support and ice is applied to reduce swelling.
These fractures are stable and require 3 weeks of immobilization followed by early motion. Complications frequently seen following type II and III fractures, such as neurovascular injury and compartment syndrome, are rare after type I injuries. Some authors recommend brief periods (6 hours) of observation in the ED, but in the absence of significant swelling, pain, or pulse deficits, discharge with orthopedic follow-up is acceptable.
Axiom: A cast should never be applied initially on a supracondylar fracture
Types II and III. With an intact neurovascular status, reduction of these fractures should be attempted by an experienced orthopedic surgeon. Emergent reduction by the emergency specialist is indicated only when the displaced fracture is associated with vascular compromise, which immediately threatens the viability of the extremity, where emergent orthopedic consultation is not available (Fig. 14–25).
Reduction of a supracondylar fracture. See text for discussion.
The initial step is to prepare for and administer procedural sedation, as outlined in Chapter 2.
While an assistant immobilizes the arm proximal to the fracture site, the physician holds the forearm at the wrist, exerting longitudinal traction until the length is near normal (Fig. 14–25A).
The physician now slightly hyperextends the elbow to unlock the fracture fragments while he or she applies pressure in an anterior direction against the distal humeral segment (Fig. 14–25B). At this point, medial and lateral angulation should be corrected. The assistant simultaneously exerts a gentle posteriorly directed force against the proximal humeral segment.
To complete reduction, the elbow is flexed to maintain the proper alignment and posterior pressure is applied to the distal fragment (Fig. 14–25C). The elbow should be flexed to the point where the pulse diminishes and then extended 5 to 15 degrees and the pulses rechecked and documented.
Caution: Only one attempt should be made at a manipulative reduction due to the proximity of neurovascular structures and the likelihood of injury with repeated attempts.
The extremity is immobilized in a long-arm posterior splint (Appendix A–9). Controversy exists about the position of the forearm. In the child, if there is medial displacement of the distal fragment, the forearm should be immobilized in pronation. With lateral displacement, the forearm should be immobilized in supination. Adults are generally immobilized in a neutral position or in slight pronation. A sling should be supplied for support and ice applied to reduce swelling. Postreduction radiographs for documentation of position are essential. Hospital admission for close follow-up of neurovascular status is mandatory. Delayed swelling with subsequent compartment syndrome and neurovascular compromise is common following these fractures.
Definitive treatment of displaced supracondylar fractures is operative pinning after closed reduction. Open reduction is required in a minority of cases. The most common cause of compartment syndrome in children is the displaced supracondylar fracture and for that reason, emergent (<8 hours) or urgent (within 24 hours) reduction to reduce swelling and improve venous return is required. Fortunately, prompt anatomic reduction and bony stabilization has reduced the incidence of forearm compartment syndrome even in the most severe cases.
Some authors manage type II fractures with closed reduction and casting with close follow-up. Excessive swelling may prohibit a stable closed reduction, however, and approximately 25% will ultimately require pinning due to displacement while in the cast.
Flexion Supracondylar Fracture
Displaced flexion supracondylar fractures also require orthopedic consultation for reduction. Pinning of the fracture is a frequently used treatment modality.19,20 Where there is limb-threatening neurovascular compromise and emergent orthopedic consultation is not available, an experienced emergency medicine specialist may carry out reduction. With the elbow held in flexion, longitudinal traction–countertraction is applied. The physician then exerts a gentle posteriorly directed pressure over the distal fragment. When the fragment is in position, the elbow is extended and maintained in extension. The extremity is immobilized with a long-arm posterior splint (Appendix A–9). It is our preference to position the elbow at 35 degrees short of full extension to avoid the development of delayed elbow stiffness. Some authors recommend splinting with the elbow in full extension. The patient should be hospitalized and treated with elevation, ice, and analgesics. Operative reduction of supracondylar flexion fractures is indicated when there is a failure of one attempt at manipulative reduction or there are unstable fracture fragments.
Supracondylar fractures are associated with several complications.
Neurovascular injuries may present acutely or with delayed symptoms. In all cases where vascular injury is suspected, the consideration of urgent arteriography should be discussed with the consulting orthopedic surgeon. Compartment syndrome may necessitate fasciotomy. Ulnar nerve palsy is a delayed complication.
Cubitus varus and valgus deformities are commonly seen in children. Malposition of the distal humeral fragment after reduction is the most frequent cause.
Stiffness and loss of elbow motion are common complications in adults secondary to prolonged immobilization. After a stable reduction, pronation and supination exercises should be initiated in 2 to 3 days. Within 2 to 3 weeks, the posterior splint may be removed for flexion–extension exercises.
This transverse fracture transects both condyles, but unlike the supracondylar fracture, this fracture lies within the joint capsule (Fig. 14–26). Transcondylar fractures are most often seen in patients older than 50 years with osteopenia. The distal humeral segment may be positioned anterior (flexion) or posterior (extension) to the proximal humeral segment. Therefore, the mechanisms, radiographs, and treatment are identical to those of the supracondylar extension or flexion fractures. This fracture frequently results in the deposition of callus within the olecranon and coronoid fossas with subsequent diminished range of motion. All transcondylar fractures require an urgent consultation with an orthopedic surgeon and are best managed initially in an inpatient setting.
Transcondylar fracture. A. Schematic. B. Radiograph.
An example of a flexion-type transcondylar fracture is the Posadas fracture. This fracture results in anterior displacement of the distal condylar segment (Fig. 14–27). The most common mechanism is a direct blow with the elbow in flexion that displaces the condylar fragments anteriorly. In addition to pain and swelling, there is loss of the olecranon prominence with fullness in the antecubital fossa.
The Posadas fracture is associated with a posterior dislocation of the radius or the ulna. Nondisplaced fractures of the transcondylar type are more common than displaced fractures.
The ED management is to splint the fracture in a long-arm posterior splint (Appendix A–9) without repositioning the arm because flexion or extension of the joint may result in serious limb-threatening vascular compromise. These fractures are difficult to treat, and an emergent orthopedic consult should be obtained. If there is vascular compromise initially, traction with an olecranon pin is the treatment of choice.
Posadas fractures are associated with several complications, including acute or delayed neurovascular compromise. Diminished range of motion may be secondary to inadequate reduction or callus formation within the joint.
Intercondylar fractures generally occur in patients older than 50 years. This is actually a supracondylar fracture with a vertical component (Fig. 14–28). The terms T and Y indicate the direction of the fracture line. T fractures have a single transverse line, whereas Y fractures present with two oblique fracture lines through the supracondylar humeral column. Classification is based on the amount of separation between the fracture fragments and is broadly divided into (1) nondisplaced fractures and (2) displaced, rotated, or comminuted fractures.
Intercondylar fractures. A. Schematic. B. Radiograph.
A nondisplaced fracture has no displacement between the capitellum and the trochlea. A displaced fracture exists when there is separation between the capitellum and the trochlea without rotation in the frontal plane. This indicates that the capsular ligaments are intact and holding the fragments in their normal position. Displacement with rotation exists when there is separation between the capitellum and the trochlea combined with rotation of the fragments. Rotation is secondary to the pull of the muscles inserting on the epicondyles. Severe comminution of the articular surface and wide separation of the humeral condyles may also occur.
The most common mechanism is a direct blow driving the olecranon into the distal humerus at the trochlea. The position of the elbow at the time of impact determines whether there will be extension or flexion displacement of the fragments. Extension or posterior displacement of the fragments is more commonly seen. Rotation frequently accompanies these fractures because of the pull of the muscles inserting on the epicondyles. The condyles may separate from each other and from the humeral shaft. The degree of separation is dependent on the direction and force of injury along with the muscular tone. Generally, larger condylar displacements are associated with greater offending forces.
On examination, there is shortening of the forearm. With extension fractures, there is a concavity of the posterior arm with prominence of the olecranon.
AP and lateral views may demonstrate comminution, and overlapping bony edges may make interpretation difficult. In comminuted fractures difficult to visualize on plain films, CT is often helpful to the surgeon planning operative therapy.21
Neurovascular injuries are infrequently associated with these fractures.
This is a stable fracture and can be initially treated with a long-arm posterior splint with the forearm in a neutral position (Appendix A–9). Sling and elevation with ice packs should be used early. Active motion exercises can be started within 2 to 3 weeks.
Displaced, Rotated, or Comminuted
These fractures are uncommonly seen, difficult to treat, and require an emergent orthopedic consultation. Operative treatment of these fractures, which was once considered treacherous, is now the treatment of choice. In patients with contraindications to surgery, other means of treatment such as olecranon pinning with traction may be used. The therapeutic program selected depends on the type of fracture, the activity level of the patient, and the judgment and past experiences of the consulting orthopedic surgeon. ED care involves splinting the fracture in the position of presentation and applying ice. Surgical fixation and traction are the two most commonly selected therapeutic modalities. In older patients with severely comminuted fractures, elbow replacement may be considered.22
Intercondylar fractures of the distal humerus may be associated with several complications.
The most common complication is loss of elbow joint function
Neurovascular complications (rare)
Malunion and nonunion (uncommon)
The humeral condyle includes both an articular portion and a nonarticular epicondylar portion. Condylar fractures, therefore, incorporate both the articular and the nonarticular portion of the condyle into the fracture fragment. Fractures may involve either the medial (trochlea and medial epicondyle) or lateral (capitellum and lateral epicondyle) condyle.
The fracture fragment of a condylar fracture may include the lateral trochlear ridge, or it may remain attached to the proximal humeral segment.24 This distinction is important because fractures in which the lateral trochlear ridge is incorporated into the distal humeral segment demonstrate medial and lateral instability of the elbow, radius, and ulna.
Lateral Condylar Fractures
The lateral condyle is anatomically more exposed, and thus more likely to fracture (Fig. 14–29).
Lateral condylar fractures. A. Lateral trochlear ridge not included. B. Lateral trochlear ridge included.
Two mechanisms result in lateral condylar fractures. First, with the elbow in flexion a direct force applied to its posterior aspect may result in a fracture. Second, with the elbow in extension, a force causing adduction and hyperextension may result in a fracture. In children, rotation of the fracture fragment is secondary to the pull of the extensor muscles. Fragment rotation is uncommon in adults.
Physical examination typically reveals tenderness and swelling over the involved condyle.
AP and lateral views typically reveal widening of the intercondylar distance. The fractured segment may be displaced proximally, but generally it will be seen posterior and inferior to its normal position. When the lateral trochlear ridge stays with the fragment, translocation of the ulna may occur. In children in whom ossification is incomplete, comparison views should be obtained.
No associated injuries are commonly seen.
Because of the high rate of complications, all lateral condylar fractures require urgent orthopedic evaluation and follow-up.
Lateral Trochlear Ridge Not Included
When nondisplaced, the arm should be immobilized in a long-arm posterior splint with the elbow in flexion, the forearm in supination, and the wrist in extension to minimize distraction by the pull of the extensor muscles (Appendix A–9). The arm should be elevated with a sling and radiographs repeated in 2 days to ensure proper positioning. A long-arm cast can be applied when the swelling is reduced. For displaced fractures, emergent orthopedic consultation should be obtained. The preferred treatment is open reduction with internal fixation. A long-arm posterior splint (Appendix A–9) is placed in the interim.
Lateral Trochlear Ridge Included
Because this fracture is more unstable, initial therapy includes the application of anterior and posterior long-arm splints (Appendix A–10). The elbow should be in over 90 degrees of flexion with the forearm supinated and the wrist extended. Radiographs should be repeated in 2 or 3 days to ensure proper positioning and a long-arm cast applied. Displaced fractures should be referred immediately to an experienced orthopedic surgeon. These fractures are best treated with open reduction and internal fixation. Closed manipulative reductions often result in cubitus valgus deformities.
Lateral condylar fractures may result in several complications.
Cubitus valgus deformity
Lateral transposition of the forearm
Arthritis due to joint capsule and articular disruption
Delayed ulnar nerve palsy
Overgrowth with subsequent cubitus varus deformity in children
Medial Condylar Fractures
These fractures are less common than lateral condylar fractures (Fig. 14–30).
Medial condylar fractures. A. Lateral trochlear ridge not included. B. Lateral trochlear ridge included.
Two mechanisms result in medial condylar fractures. First, a direct force applied through the olecranon in a medial direction may fracture the medial condyle. Second, abduction with the forearm in extension may result in a fracture of the medial condyle.
Tenderness over the medial condyle with painful flexion of the wrist against resistance is frequently noted.
Similar findings as with the lateral condylar fractures are noted, except the distal fragment tends to be pulled anteriorly and inferiorly by the flexor muscles.
No associated injuries are commonly seen.
Lateral Trochlear Ridge Not Included
A long-arm posterior splint is applied with the elbow flexed, the forearm in pronation, and the wrist in flexion (Appendix A–9). Orthopedic follow-up with repeated radiographs to exclude delayed displacement is strongly urged. Displaced fractures require immobilization, ice, and elevation with emergent referral for surgical fixation.
Lateral Trochlear Ridge Included
Because this fracture is more unstable, initial therapy includes the application of anterior and posterior long-arm splints (Appendix A–10). The elbow should be in over 90 degrees of flexion with the forearm pronated and the wrist flexed. Radiographs should be repeated in 2 or 3 days to ensure proper positioning and a long-arm cast applied. ED management of displaced fractures includes immobilization, ice, elevation, and emergent referral for surgical fixation.
Medial condylar fractures are associated with the following complications:
Malunion with subsequent cubitus varus deformity
Ulnar nerve palsy
Articular surface fractures include the capitellum and trochlea and are very uncommon as isolated injuries, but may be seen in conjunction with posterior dislocations of the elbow (Fig. 14–31). Trochlear fractures are extremely rare and require emergent orthopedic evaluation and treatment. Capitellum fractures constitute only 0.5% to 1% of all elbow injuries, and 6% of distal humerus fractures.25
Articular surface fractures. A. Capitellum fracture. B. Trochlea fracture.
The fracture mechanism is usually the result of a blow inflicted on the outstretched hand. The force is transmitted up the radius to the capitellum. The capitellum has no muscular attachments, and, consequently, the fragment may be displaced. In some circumstances, secondary displacement occurs from elbow motion.
Initially, there may be a silent interval where there is an absence of signs and symptoms. Later, as blood distends the joint capsule, pain and swelling may become quite severe. Anterior displacement of the fracture fragment into the radial fossa may result in incomplete painful flexion. With posterior displacement, the range of motion is complete; however, there is increased pain with flexion.
The lateral view usually demonstrates the fragment lying anterior and proximal to the main portion of the capitellum.
Radial head fractures are common. Capitellum fractures are associated with a high incidence of ulnar collateral ligament rupture.26,27
Surgical excision of a small capitellar fragment (articular cartilage and subchondral bone) has been the traditional treatment of choice, but as operative techniques improve, operative fixation is becoming more commonly performed.12,25 ED management consists of immobilization in a posterior splint, ice, elevation, and analgesics. If a large fragment is present, or a piece of the trochlea is involved, emergent orthopedic consultation for operative reduction is indicated. Both closed and open techniques have been described.12 An accurate reduction is imperative to ensure normal motion of the radiohumeral joint.
Capitellum fractures are associated with the following complications:
Avascular necrosis of the fracture fragment
Restricted range of motion
Epicondyle fractures are most commonly seen in children (Fig. 14–32).
Epicondylar fractures. A. Medial epicondyle. B. Lateral epicondyle.
Medial Epicondyle Fracture
Medial epicondyle fractures are much more common than lateral (Fig. 14–32A). The ossification center for the medial epicondyle appears by age 5 to 7 and fuses to the distal humerus by approximately age 20. Medial epicondyle displacement, as an isolated injury, is uncommon. More commonly seen is the palpable avulsion fracture associated with a posterior dislocation of the elbow.
Three mechanisms are commonly associated with fractures of the medial epicondyle.
The more common avulsion fracture is associated with childhood or adolescent posterior dislocations. This fracture is rarely associated with posterior dislocations over the age of 20.
The flexor pronator tendon is attached to the medial epicondylar ossification center. Repeated valgus stress on the elbow may result in a fracture with fragment displacement distally. This is commonly seen in adolescent baseball players and is called “little league elbow.”
Isolated medial epicondylar fractures in adults are usually due to a direct blow.
If this fracture is associated with a posterior dislocation, the elbow will be in flexion and there will be a prominence of the olecranon. Isolated fractures produce localized pain over the medial epicondyle. Pain is increased with flexion of the elbow and the wrist or with pronation of the forearm.
Caution: When assessing this fracture, examine and document ulnar nerve function before initiating therapy.
Comparison views are essential in children and adolescents. Displaced fragments may migrate and become intra-articular.
Caution: If the fragment has migrated to the joint line, it should be considered intra-articular.
The age at which the epicondyles ossify and fuse should be considered before diagnosing a fracture (Fig. 14–33). The medial epicondyle appears at ages 5 to 7 and fuses at ages 18 to 20. The lateral epicondyle appears at ages 9 to 13 and fuses at ages 14 to 16. For further information, the reader is referred to Chapter 6.
A medial epicondyle fracture in a child.
The most common associated injury is posterior dislocation of the elbow.
Fragments that are displaced <4 mm, as determined by measuring the clear space between the fracture fragment and the humerus, can be immobilized in a long-arm posterior splint (Appendix A–9). The elbow and the wrist should be flexed with the forearm pronated.
If the fracture is associated with an elbow dislocation, the dislocation is reduced first (refer to the section on “Elbow Dislocations”), and the fracture fragments are then assessed. If the epicondyle is within the joint, open reduction is indicated.
Medial epicondylar fractures are associated with ulnar nerve bony entrapment if persistent displacement is present. Other complications are related to posterior elbow dislocation, and the reader is referred to that section for further details.
Lateral Epicondyle Fracture
This is an exceedingly rare injury that usually is the result of a direct blow. It is much more common for the condyle to fracture than the epicondyle. Most fractures are nondisplaced and can be treated in a similar manner to lateral condylar fractures (Fig. 14–32B).