Chapter 14: Elbow

The elbow is a hinge joint composed of three articulations: humeroulnar, radiohumeral, and radioulnar. These articulations provide a high degree of inherent stability to the elbow and are supported by several ligamentous structures—the radial collateral, ulnar collateral, annular ligaments, and the anterior capsule (Fig. 14–1). The biceps, triceps, brachialis, brachioradialis, and anconeus provide muscular dynamic stability.

Elbow injuries are caused by a direct blow, valgus stress from throwing, or axial compression. Acute traumatic injuries may result in fractures to the radius and ulna or the distal humerus. With repetitive valgus stress, patients may develop chondromalacia, loose bodies in the posterior or lateral compartments, injury to the ulnar collateral ligament, injury of the flexor pronator muscle group, osteochondritis dissecans, or ulnar neuritis.¹

The distal humerus is divided into two condyles (Fig. 14–2). The coronoid fossa is the area of very thin bone that serves as the surface of contact with the coronoid process of the olecranon when the elbow goes into full flexion. The articular surface of the medial condyle is called the trochlea. It serves as the articulating surface of the ulnar olecranon. The lateral articular surface of the distal humerus is the capitellum, which articulates with the radial head.

The nonarticular portions of the condyles are called epicondyles, and serve as points of attachment for the muscles of the forearm—pronator-flexors attach to the medial epicondyle, whereas supinator-extensors attach to the lateral epicondyle. Just proximal to either epicondyle are the supracondylar ridges that also serve as points of attachment for the forearm muscles. The muscles surrounding the elbow impact fracture alignment (Figs. 14–3 and 14–4). With a fracture, continual traction by these muscles results in displacement of the fragments, and on occasion, nullification of an adequate reduction.

Three bursae around the elbow are of clinical significance: one between the olecranon and the triceps, another between the radius and the insertion of the biceps tendon, and finally the olecranon bursa, which lies between the skin and the olecranon process. Bursitis about the elbow most commonly involves the olecranon bursa (Fig. 14–5).

Examination

Examination of the elbow reveals several palpable bony landmarks. Laterally, three bony prominences make up a triangle and correspond to the olecranon, radial head, and lateral epicondyle. An effusion of the elbow is indicated by swelling and tenderness between the lateral epicondyle and olecranon.

The neurovascular structures of the elbow include the brachial artery and the radial, ulnar, and median nerves (Fig. 14–6). The ulnar nerve is palpated on the medial surface of the elbow as it runs through the cubital tunnel. Assessment of the neurovascular structures is of critical importance when evaluating and treating elbow fractures. The examination should be repeated after manipulation or splinting and at regular intervals as edema from a fracture may result in neurovascular compromise. Further discussion will be included under the management of specific fractures.

Imaging

The radiographic examination of the elbow should consist of a minimum of an anteroposterior (AP) and lateral radiograph (Fig. 14–7). Oblique views will aid in the diagnosis of some elbow fractures. In most cases, the involved joint should not be extensively manipulated until radiographs have been obtained to exclude apparent fracture and dislocation.

Anteroposterior View

A diagnostic aid in evaluating radiographs of suspected supracondylar fractures in children is the carrying angle. The intersection of a line drawn through the midshaft of the humerus and a line through the midshaft of the ulna on an AP extension view determines the carrying angle (Fig. 14–8). Normally, the carrying angle is between 0 and 12 degrees. Traumatic or asymmetric carrying angles of >12 degrees are often associated with fractures.

Lateral View

The lateral view at 90-degree flexion is the most important view as it allows the physician to note the radiocapitellar and anterior humeral line as well as evaluate the fat pads.

Radiocapitellar Line

A line drawn through the midportion of the radius normally passes through the center of the capitellum on the lateral view of the elbow. In a fracture at the epiphysis of the radial head in children, this line will be displaced away from the center of the capitellum. This may be the only finding suggesting a fracture in a child. In adults, displacement of the radial head, as seen in the Monteggia fracture, will also reveal an abnormal radiocapitellar line (Fig. 14–9).

Anterior Humeral Line

The anterior humeral line is a line drawn on a lateral radiograph along the anterior surface of the humerus through the elbow (Fig. 14–10). Normally, this line transects the middle third of the capitellum. With a supracondylar extension fracture, this line will either transect the anterior third of the capitellum or pass entirely anterior to it.

Fat Pads

The presence of a bulging anterior fat pad (sail sign) or a posterior fat pad sign is indicative of significant joint capsule distension (Fig. 14–11). The anterior fat pad is over the coronoid fossa and is seen occasionally as a thin radiolucent line just anterior to the fossa in many normal radiographs. With a fracture, the joint capsule may be distended with blood and the anterior fat pad will be displaced anteriorly away from the coronoid fossa. The posterior fat pad lies over the olecranon fossa. Because the olecranon fossa is much deeper, the posterior fat pad is rarely visualized on normal radiographs with the elbow flexed at 90 degrees. Only with joint capsule distention, as with an intra-articular fracture with a capsular hematoma, will the posterior fat pad be visualized. In a child, because cartilaginous growth and various centers of ossification make fracture identification difficult, the detection of a posterior fat pad can be regarded as an intra-articular fracture until proven otherwise.

The incidence of a visable radiographic fat pad in elbow fractures without other evidence of fracture ranges widely from 6% to 76%.^2,3 When magnetic resonance imaging (MRI) was performed on this patient population, occult fractures were discovered in 75% of cases.^4,5 Fractures of the radial head were most common, accounting for 87% of the occult fractures. Fractures of the olecranon and lateral epicondyle accounted for an equal number of the remaining fractures. Recognition of the fracture did not change management in any of the 20 patients studied.⁴

Olecranon Fractures

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.

Mechanism of Injury

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.

Examination

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.

Imaging

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

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.

Associated Injuries

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.

Treatment

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.

Complications

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.

Mechanism of Injury

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.

Examination

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.

Imaging

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.

Associated Injuries

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.

Treatment

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 (Intra-articular)

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

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.

Comminuted

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:

1. The skin of the lateral elbow should be prepped using sterile technique.

2. 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.

3. The skin should be anesthetized with lidocaine.

4. 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).

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

Mechanism of Injury

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.

Examination

Tenderness and swelling over the antecubital fossa is noted frequently.

Imaging

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

Treatment

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

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.

Complications

Coronoid process fractures are infrequently associated with the development of osteoarthritis.

Supracondylar Fractures

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

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.

Mechanism of Injury

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.

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.

Examination

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.

Imaging

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.

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.

Associated Injuries

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.

Treatment

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.

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).

1. The initial step is to prepare for and administer procedural sedation, as outlined in Chapter 2.

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).

3. 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.

4. 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.

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.

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.

Complications

Supracondylar fractures are associated with several complications.

1. 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.

2. Cubitus varus and valgus deformities are commonly seen in children. Malposition of the distal humeral fragment after reduction is the most frequent cause.

3. 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.

Transcondylar Fractures

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.

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

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.

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.

Mechanism of Injury

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.

Examination

On examination, there is shortening of the forearm. With extension fractures, there is a concavity of the posterior arm with prominence of the olecranon.

Imaging

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

Associated Injuries

Neurovascular injuries are infrequently associated with these fractures.

Treatment

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.

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

Complications

Intercondylar fractures of the distal humerus may be associated with several complications.

1. The most common complication is loss of elbow joint function

2. Post-traumatic arthritis²³

3. Neurovascular complications (rare)

4. Malunion and nonunion (uncommon)

Condylar Fractures

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).

Mechanism of Injury

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.

Examination

Physical examination typically reveals tenderness and swelling over the involved condyle.

Imaging

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.

Associated Injuries

No associated injuries are commonly seen.

Treatment

Because of the high rate of complications, all lateral condylar fractures require urgent orthopedic evaluation and follow-up.

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.

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.

Complications

Lateral condylar fractures may result in several complications.

1. Cubitus valgus deformity

2. Lateral transposition of the forearm

3. Arthritis due to joint capsule and articular disruption

4. Delayed ulnar nerve palsy

5. Overgrowth with subsequent cubitus varus deformity in children

Medial Condylar Fractures

These fractures are less common than lateral condylar fractures (Fig. 14–30).

Mechanism of Injury

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.

Examination

Tenderness over the medial condyle with painful flexion of the wrist against resistance is frequently noted.

Imaging

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.

Associated Injuries

No associated injuries are commonly seen.

Treatment

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.

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.

Complications

Medial condylar fractures are associated with the following complications:

1. Post-traumatic arthritis

2. Malunion with subsequent cubitus varus deformity

3. Ulnar nerve palsy

Capitellum Fractures

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

Mechanism of Injury

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.

Examination

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.

Imaging

The lateral view usually demonstrates the fragment lying anterior and proximal to the main portion of the capitellum.

Associated Injuries

Radial head fractures are common. Capitellum fractures are associated with a high incidence of ulnar collateral ligament rupture.^26,27

Treatment

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.

Complications

Capitellum fractures are associated with the following complications:

1. Post-traumatic arthritis

2. Avascular necrosis of the fracture fragment

3. Restricted range of motion

Epicondyle Fractures

Epicondyle fractures are most commonly seen in children (Fig. 14–32).

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.

Mechanism of Injury

Three mechanisms are commonly associated with fractures of the medial epicondyle.

1. 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.

2. 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.”

3. Isolated medial epicondylar fractures in adults are usually due to a direct blow.

Examination

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.

Imaging

Comparison views are essential in children and adolescents. Displaced fragments may migrate and become 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.

Associated Injuries

The most common associated injury is posterior dislocation of the elbow.

Treatment

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.

Complications

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).

Elbow Dislocations

Elbow dislocations are among the most commonly seen dislocations in the body, second in frequency only to dislocations of the shoulder and the fingers. The most common elbow dislocation is a posterior dislocation, which accounts for 90% of cases (Fig. 14–34).^28,29 Anterior, medial, and lateral dislocations make up the remainder of the cases. Lateral and medial dislocations can occur in isolation, but are more often seen in combination with either posterior or anterior dislocations or with fractures. Anterior dislocation of the elbow is almost always associated with fractures.

Posterior Dislocation

Posterior dislocations, in which the olecranon is displaced posteriorly in relation to the distal humerus, account for the majority of dislocations seen at the elbow (Fig. 14–34A).³⁰ Elbow dislocations are classified as simple or complex, depending on whether there is a fracture in addition to the dislocation. Simple dislocations are more common than complex.

Mechanism of Injury

The mechanism of injury is a fall on the extended and abducted arm. A combination of valgus, supination, and axial forces acts to tear ligamentous attachments and allows the joint to become dislocated.

Examination

Patients with posterior dislocations present to the ED with the limb held in flexion at 45 degrees. The olecranon is prominent posteriorly, and there is usually moderate swelling and deformity at the joint (Figs. 14–35 and 14–36). The peripheral nerves and the distal pulses should be examined.

Significant swelling may make the diagnosis difficult as this may occur with dislocation or supracondylar fracture. If one palpates the two epicondyles and the tip of the olecranon in patients with a supracondylar fracture, they will be in the same plane, whereas with dislocations, the olecranon will be displaced from the plane of the epicondyles on palpation.

Imaging

Plain radiographs are diagnostic, and reveal an empty olecranon fossa posterior to the distal humerus (Fig. 14–37). Radiographs should be obtained both before and after reduction. Associated fractures include the coronoid process, radial head, and occasionally the humeral epicondyles or capitellum (Fig. 14–38). Small fractures of the coronoid are common and should not impact management.³¹ When both the coronoid and radial head are fractured in a posterior elbow dislocation, the injury is referred to as the “terrible triad.”³¹ Fractures are present on 12% to 60% of plain radiographs.²⁹

Associated Injuries

Commonly associated injuries are to the peripheral nerves, especially the ulnar nerve, and function should be checked before and after reduction.³² Ulnar nerve injury occurs in 8% to 21% of patients with posterior elbow dislocations, but usually resolves spontaneously with conservative management.²⁹ Injury to the brachial artery is rare with posterior dislocations of the elbow.^29,32 Median nerve entrapment may also occur in patients with posterior dislocations.³⁰

Complex elbow dislocations are those that occur with a large intra-articular fracture. The radial head and coronoid are the most commonly associated fractures and occur with an incidence ranging from 12% to 60%. During operative exploration, osteochondral injuries are seen in most cases of acute elbow dislocations. In patients with the “terrible triad” (elbow dislocation with radial head and coronoid process fractures), significant disability frequently occurs.

A fractured medial epicondyle can sometimes become entrapped in the joint, necessitating open reduction. Fractures of the coronoid process are commonly associated injuries, and will usually come into near-normal opposition once reduction occurs. Large fragments that are displaced may require operative fixation.

All elbow dislocations that are not associated with concomitant elbow fractures will demonstrate rupture of the medial and lateral ligaments.¹¹ Although these ligaments are primary stabilizers of the elbow, surgical repair is rarely needed because the flexor and extensor muscles act as a strong secondary stabilizer that resists redislocation. Recurrent instability in a simple elbow dislocation is seen in only 1% to 2% of cases.²⁹

The wrist and shoulder must be examined thoroughly, as additional upper-extremity injuries occur in 10% to 15% of cases.^29,33

Treatment

Early reduction is advocated, as delay may damage the articular cartilage or result in excessive swelling or circulatory compromise. If the elbow remains unreduced for more than 7 days, the utility of closed reduction is minimal. Reduction is best accomplished after administering procedural sedation, as described in Chapter 2. Intra-articular local anesthetic is also an option to aid in the reduction. Several reduction techniques have been described to reduce a posterior dislocation. The techniques below apply to posterior dislocation without a medial or lateral component. The Stimson technique is the preferred method because it causes the least amount of discomfort and associated injuries. Whatever technique is employed, it is recommended that slow, continuous, and gentle forces be applied to limit additional soft-tissue injury.

The forearm is supinated and the elbow is left in slight flexion (approximately 30 degrees). Supination is used to minimize further trauma to the coronoid process. The physician stabilizes the distal humerus with the nondominant hand and distracts the forearm with the dominant hand. A slow, continuous, gentle, longitudinal traction with gradual flexion will reduce the elbow (Fig. 14–39A). If an assistant is available, they can grasp the distal humerus while the physician uses both hands to provide traction. Reduction can also be assisted by pressure applied over the olecranon. Hyperextension is contraindicated during reduction because it can lead to neurovascular injury (i.e., median nerve entrapment or brachial artery injury), increase the risk of developing myositis ossificans by damaging muscle, or injure articular surfaces.

While supine, the patient’s elbow is flexed, forearm supinated, and shoulder abducted. The physician places their elbow onto the patient’s distal biceps and uses their hand to interlock the patient’s fingers or grab the wrist. The patient’s elbow is gradually flexed while the physician’s elbow provides countertraction (Fig. 14–39B and Video 14–1). The end result is a lever with a sufficient longitudinal force to reduce the elbow.³⁴

This is a modification of the Stimson technique used in shoulder reductions (Fig. 14–39C). The patient should be placed in the prone position with the dislocated elbow hanging perpendicular to the table. A small pillow or folded sheet should support the humerus just proximal to the elbow joint. Weights are then suspended from the wrist with the elbow flexed approximately 30 degrees from the extended position. Over a period of several minutes, the patient’s elbow dislocation will reduce. We prefer beginning with approximately 5 lb of weight, which can be increased if needed. This technique is preferred by many because it is least likely to produce forceful manipulation that can result in myositis ossificans.

This method involves gentle disengagement of the coronoid process without excessive traction and hyperextension that can lead to soft-tissue damage when the olecranon impinges on the lower humerus.³⁵ To perform this reduction, the emergency physician stands on the contralateral side of the patient’s injured elbow. With one hand, the patient’s forearm is grasped (Fig. 14–39D and Video 14–2). With the other hand, the elbow is grasped such that the thumb is placed over the patient’s olecranon and the fingers are over the forearm. Gentle traction is applied while the patient’s elbow is gradually flexed to disengage the coronoid process from the lower humerus. At the same time, the olecranon is pushed into position with the thumb. This procedure takes about 5 minutes to complete and has a 95% success rate.³⁵

Successful reduction is frequently heralded by a “clunking” sound as the articular surfaces return to their normal position. After reduction, the elbow can be checked for stability by putting it through range of motion. If redislocation occurs in extension, the joint is potentially unstable. The lateral and medial ligaments can also be stress tested. If the elbow remains reduced, it is stable and is immobilized at 90 degrees in a long-arm posterior splint³¹ (Appendix A–9). If there is significant swelling, a position slightly less than 90 degrees is used. If there is any concern for potential vascular injury or compartment syndrome, the patient should be admitted after appropriate orthopedic consultation.

For patients with stable reductions who will be discharged, the length of immobilization is approximately 5 to 7 days, so follow-up should occur within this time-frame. At that time, full range of motion exercises should begin with interval use of a splint or sling for comfort and support. Immobilization for >3 weeks is associated with diminished range of motion.²⁹

Surgery is indicated in cases where closed reduction is unsuccessful, when redislocation occurs with 50 to 60 degrees of flexion, or when unstable fractures are present around the joint.^29,36 Small coronoid fractures do not require further management. Radial head fractures and large coronoid fractures (involving at least 50% of the coronoid process) will usually require operative repair following closed reduction.³¹

Complications

1. Nerve injuries in up to 20%.³⁷ The most common are the ulnar and median nerves, but the radial and anterior interosseous nerves can also be affected. They usually resolve with conservative management.

2. Post-traumatic joint stiffness. Loss of the terminal 15 degrees of elbow extension after dislocation is common.²⁹

3. Heterotopic ossification. This is common after posterior elbow dislocation (>75% of patients), but limits motion in <5%.

4. Chronic instability.

Anterior Dislocations

Anterior dislocations are far less common, occurring from a blow to the flexed elbow that drives the olecranon forward. Associated injuries to bones, vessels, and nerves around the joint are much more common with anterior dislocations, making this dislocation potentially more problematic.

On examination, the arm appears shortened and the forearm is elongated and held in supination. The elbow is usually held in full extension. The olecranon fossa is often palpable anteriorly.

All of these patients should be splinted, and the vascular and neurologic status assessed. Consultation with an orthopedic surgeon should be obtained for immediate reduction. Many of these dislocations are open, and vascular damage is quite common. Complete avulsion of the triceps mechanism is another commonly associated soft-tissue injury.

Olecranon Bursitis

Olecranon bursitis is the most common form of elbow bursitis seen in the ED. It is secondary to trauma, overuse, crystal disease, autoimmune disease, or infection.^38,39

One-third of the cases are infectious (septic), and it should be noted that trauma may cause both septic and nonseptic bursitis.^38,40–42 Of more than 150 bursae in the human body, the olecranon bursa is the most commonly infected.^39,40 Staphylococcus aureus is responsible for approximately 80% to 90% of cases.^43–45 Other risk factors for septic olecranon bursitis include alcoholism, immunocompromised states, and preexisting bursal disease.^40,45 Approximately one-third of patients with septic olecranon bursitis have a history of a previous episode of olecranon bursitis.⁴²

Examination

On examination of the patient with olecranon bursitis, the examiner will note swelling in the posterior aspect of the elbow with slight restriction of flexion due to the inflamed bursa (Fig. 14–40).⁴⁴ The bursa will be tender to palpation. Erythema may be present in patients with both septic and nonseptic bursitis.⁴² Patients with septic bursitis usually seek medical attention earlier and are more likely to have fever.^40,42 In patients with bursitis caused by gout or infectious processes, there will be surrounding inflammatory reaction and pain with motion of the elbow. Warmth may be present in both septic and nonseptic bursitis, but the surface temperature between the involved bursa and the unaffected side is significantly greater when infection is the underlying cause.³⁹

Diagnosis

Early recognition of septic bursitis is critical to prevent severe sequelae.³⁸ For this reason, aspiration is recommended in all cases, and fluid is sent for analysis for crystals, cell count, Gram stain, and culture. A purulent aspirate is helpful in diagnosing septic bursitis, but serosanguinous fluid may be septic or nonseptic. The cell count in patients with septic bursitis is usually >1000 WBC/mm³ with a predominance of neutrophils.^39,40,43 Gram stain will be positive in over half of the cases of septic bursitis.⁴² Frequently, septic olecranon bursitis cannot be ruled out definitively after aspiration, and presumptive antibiotic treatment must be started until the results of the cultures have returned.⁴⁶

Treatment

Noninfectious olecranon bursitis is treated by aspiration and application of a compressive dressing with local heat and preventive measures directed at the inciting cause. Nonsteroidal anti-inflammatory drugs and intrabursal steroid injections will hasten resolution. Intrabursal injection of methylprednisolone acetate may alleviate symptoms by promptly reducing inflammation.³⁸ It should be noted that steroids should be avoided in any patient suspected of having septic bursitis.

In cases of suspected septic bursitis, patients should have the bursa aspirated and they should be given antibiotics. Selective outpatient management with oral antibiotics is successful in most cases.^44,47 Treatment failures include those with extensive infection or who are immunocompromised.⁴³ Aspiration may need to be repeated, however, and rarely, incision and drainage in the operating room is required. Percutaneous tube placement for suction irrigation has been attempted and may be beneficial for those with severe septic bursitis.^38,40 Admission for intravenous antibiotics effective against S. aureus may be required for severe cases.^39,43,44

Overuse Elbow Injuries

The majority of elbow injuries occur from chronic use, particularly in athletes.⁴⁸ One helpful way to evaluate a patient with elbow pain is to consider the location of the pain as indicative of potential causes. This information, combined with a thorough history regarding the mechanism of injury and physical examination findings is frequently diagnostic.

Anterior elbow pain is a common presenting problem, particularly in the young athlete. It is usually caused by a stretch or tear of the anterior capsule, distal biceps, or brachialis tendons. This injury can be caused by hyperextension from fall onto the extended elbow. “Climber’s elbow” is a strain of the brachialis tendon.

Ectopic bone may deposit after a traumatic blow to the anterior arm. This usually occurs within the brachialis muscle 3 weeks after the injury. Prevention with a nonsteroidal anti-inflammatory agent and early range of motion is of paramount importance. Anterior elbow pain may also result from median nerve entrapment such as with the pronator syndrome.

Medial elbow pain may result from a variety of conditions, and is much more common. A medial epicondyle fracture or stress fracture can occur. Medial epicondylitis is due to tendonitis of the flexor or pronator muscle group. An unusual condition called snapping elbow syndrome occurs when the ulnar nerve snaps out of the cubital tunnel. Medial elbow pain may result from instability caused by acute or chronic ulnar collateral ligament disruption. Ulnar neuritis is a common cause of medial elbow pain in athletes because of the ulnar nerve’s superficial location at the cubital tunnel and its unfavorable response to valgus stresses. Compression can occur proximal to the cubital tunnel because of a tight intramuscular septum. The earliest symptom is medial joint line pain; clumsiness; or heaviness of the hand, fingers, or both. This is associated with or exacerbated by throwing or overhead activity and may manifest as numbness and tingling in the little and ring fingers.⁴⁹

Posterior elbow pain is less common than medial or lateral elbow pain but more common than anterior pain. Abnormal stresses may cause pain at the attachment of the triceps or olecranon apophysis, which may present in a similar fashion to Osgood–Schlatter disease.⁵⁰ Triceps tendonitis is an uncommon cause of posterior elbow pain and is treated with rest. Triceps tendon rupture is very uncommon. A stress fracture of the olecranon is also an uncommon cause of elbow pain that occurs in athletes who throw. Olecranon bursitis, is by far the most common condition in this group.

Lateral elbow pain is the most common location of elbow pain in the general population. Lateral epicondylitis, discussed subsequently, is the most common cause. Radial nerve entrapment at the elbow can occur alone or in conjunction with lateral epicondylitis.⁵¹

Epicondylitis (Tennis Elbow)

Epicondylitis can occur on the lateral or medial side of the distal humerus at the site of tendinous insertion of the muscles of the forearm. Both injuries are usually the result of chronic overuse secondary to both recreational and occupational pursuits that require a repeated rotary motion.⁵²

Lateral epicondylitis most often occurs in the fourth and fifth decades. It is usually referred to by the nondescriptive term, “tennis elbow,” because 10% to 50% of tennis players will develop this condition.⁵¹ Many entities have been implicated, including arthritis of the radiohumeral joint, radiohumeral bursitis, traumatic synovitis of the radiohumeral joint, and periostitis of the lateral epicondyle. At present, none of these can be considered the sole cause of this condition.^51–54 The underlying feature is the presence of tears in the aponeurosis of the extensor tendons.⁵² Many patients with tennis elbow have microavulsion fractures of the lateral epicondyle in addition to microscopic tears in the tendon proper.⁵⁵

The patient usually presents with a history of a gradual onset of a dull ache along the outer aspect of the elbow referred to the forearm. The pain increases with grasping and twisting motions.⁵⁵ Tenderness is localized over the lateral epicondyle. A reliable test for tennis elbow is elicited by asking the patient to actively extend the wrist and supinate the forearm against resistance (Fig. 14–41). In patients with tennis elbow, this maneuver intensifies the discomfort.⁵⁶ The neurologic examination should be normal. MRI is helpful in identifying areas of inflammation suggestive of lateral epicondylitis. Ultrasound also may be useful in making the diagnosis.⁵⁷

The ED treatment of this condition is to splint the elbow in a flexed position with the forearm supinated and the wrist extended. The patient should be advised to apply heat to the elbow and rest. Anti-inflammatory agents, such as ibuprofen, are of value. Counterforce bracing or “tennis elbow bands” are quite effective in reducing the symptoms and allowing the individual to continue normal activity (Fig. 14–42).^58,59

Corticosteroid injections have been shown to be safe and beneficial, with their effects lasting 2 to 6 weeks. The technique for injection requires the elbow to be flexed to 45 degrees. The area of greatest tenderness is identified; the needle is inserted at 90 degrees down to the bone, and then pulled back 1 to 2 mm before injecting.⁶⁰

Treatment with shock therapy, ultrasound, and laser have proven of no value and in fact, simple stretches and strengthening exercises are the most useful adjuncts as the patient improves.^61–63 Surgical intervention may prove beneficial in refractory cases.⁶³

Golfer’s Elbow

Medial epicondylitis (golfer’s elbow), is inflammation at the origin of the wrist flexors. It is characterized by pain over the medial epicondyle and medial pain on forced flexion of the wrist (Fig. 14–43). While seen in golfers, this injury occurs more frequently in individuals who routinely perform household chores, manual labor, or other tasks involving repetitive movements. The treatment of medial epicondylitis is similar to that of lateral epicondylitis. Because of the close proximity of the ulnar nerve, local anesthetic used with the corticosteroid injection may cause a temporary paralysis of the ulnar nerve.

Conservative management is curative in most cases, but may take many months. As a last resort, surgical intervention may be necessary.⁴⁹

Osteochondritis Dissecans

Osteochondritis dissecans refers to a condition in which focal subchondral bone necrosis leads to the disruption of articular cartilage and displacement of a bony fragment into the joint space.^64–66 The condition is rare and most commonly occurs within the femoral condyles at the knee (75% of cases). Other sites include the talar dome and the capitellum of the humerus. Within the elbow, the condition most commonly affects adolescent (ages 12–20) athletes who overload and hyperextend the joint.⁶⁷ An adult form has been identified, although it is unclear whether or not these patients were merely undiagnosed as children.⁶⁵

Gymnasts, due to the nature of their sport, are particularly susceptible to this condition. The symptoms include locking, “giving way,” and crepitus on range of motion. Radiographs may reveal a loose body within the joint or demonstrable osteochondritis dissecans. MRI is often helpful in suspicious cases where the radiographs are negative.^67–69

Treatment is conservative, unless there are loose bodies within the joint that require removal. The athlete must refrain from competitive sports for 6 to 8 weeks.⁶⁵ Conservative treatment for acute exacerbations consists of splinting the elbow for 3 to 4 days, anti-inflammatory medications, and the application of heat. If mechanical symptoms occur and persist, arthroscopic intervention to remove loose bodies is necessary.^69,70

For more information, the reader is referred to Chapter 6.

Ligamentous Injuries

Sprains involving the ulnar and radial collateral ligaments of the elbow follow acute injuries or chronic overuse. These injuries are diagnosed by appropriate stress testing of the involved ligaments (Fig. 14–44). When there is opening of the joint on a stress examination, one must always assess the neurologic status to exclude associated deficits.⁷¹ Treatment with immobilization of the elbow in a flexed position is the appropriate ED management in most cases.

Ulnar Collateral Ligament Injury

Ulnar collateral ligament injury is a common problem in overhead throwers.⁷² The ligament complex comprises three portions—an anterior bundle, posterior bundle, and oblique bundle. A sprain or rupture of this ligament compromises medial and valgus stability in the elbow joint.⁷³ Thus, an accurate diagnosis, indicating the degree of tear, is important to determine appropriate treatment.

The history and examination are crucial to diagnosing ulnar collateral ligament insufficiency, in that there is usually tenderness medially over the ligament. Point tenderness inferior and distal to the medial epicondyle is elicited. Posterior medial joint line tenderness is also present, and one must examine the ulnar nerve within the ulnar groove, as this may sometimes be involved in the injury.⁷³ Routine radiographs may show calcification within the ligament or chronic traction spurs from repetitive stresses.

Rest, ice, and anti-inflammatory medications are the mainstay of therapy.^73,74 The treatment of any patient with significant opening should include a posterior mold with the elbow in 90 degrees of flexion. Because the elbow is a hinge joint, opening indicates a significant disruption of the joint capsule. When medial joint opening occurs, there may be an associated injury (stretch) of the brachial artery and therefore pulses should always be documented. In severe cases, surgical intervention may be necessary to reestablish stability.^11,73,75 Arthroscopy is performed initially.^76,77 Reconstruction, “Tommy John surgery,” may be needed in athletes as this may be a career-ending injury.^73,78,79

Neuropathies

Compressive neuropathies can be subtle and are often overlooked in the upper extremity. These nerve injuries are classified into three types: neurapraxia, axonotmesis, and neurotmesis, as described in Chapter 1. Few of the lesions ever fit exclusively into one category.

Neurapraxia is the mildest form, which is characterized by reduced function but anatomic continuity within the nerve. This injury is caused by loss of axon excitability or segmental demyelination. This is the most common nerve injury. In axonotmesis, there is axonal injury and distal degeneration, with the connective tissue supporting the nerve structure remaining intact. In neurotmesis, there is complete disruption of the nerve.⁸⁰

Radial Neuropathy

Radial neuropathy that occurs at or distal to the radial groove of the humerus will retain motor strength to the triceps muscle. However, motor deficits will include paralysis of the brachioradialis, supinator, and extensors of the wrist—identified by wrist drop on examination (Fig. 14–45). Sensory deficits include loss of sensation to the dorsal web space between the thumb and index fingers.

High Radial Nerve Palsy

Injury to the radial nerve above the elbow is unusual and usually secondary to trauma such as crutch use or tourniquets. This injury is differentiated from other forms of radial nerve injury because the triceps muscle will be involved.

When compression occurs as the radial nerve spirals around the humerus, the injury is sometimes referred to as “Saturday night palsy.” This condition can occur after humerus fractures or after compression (i.e., intoxicated patients who fall asleep with their arm resting on the back of a chair).

Nerve injury in the spiral groove may also be seen in injuries from gymnastics or wrestling. Compression may occur at the fibrous area around the origin of the lateral head of the triceps or at the intermuscular septum. In this compressive injury, a mixed motor and sensory involvement occurs.

Conservative treatment with a volar splint with the wrist in 20 degrees of extension will often result in complete recovery, although the time required varies.⁸¹ Surgical exploration of the radial nerve is indicated only when symptoms persist or there is evidence of degeneration.

Radial Tunnel Syndrome

The radial tunnel is defined by the anatomic structures from the elbow to the distal extent of the supinator muscle.⁸² This is the most common site for a compressive neuropathy of the radial nerve. Compression is usually due to a fibrous band of tissue and may occur at many sites within the radial tunnel.^83–85 Patients complain of soreness and aching just distal to the lateral epicondyle over the extensor muscle mass. This condition can often be confused with lateral epicondylitis, but on examination, maximal tenderness will be elicited over the anterior radial neck. There is a chronic deep ache that is common at night that is unlike the sharp, knifelike pain of lateral epicondylitis.^82,86–88 There is no true sensory involvement because the sensory branch of the radial nerve is more superficial and does not pass through the radial tunnel. Motor weakness is uncommon.⁸⁹ The patient with radial tunnel syndrome often exhibits pain with resisted supination of the extended forearm, which is made worse with wrist flexion.

Treatment consists of rest, anti-inflammatory drugs, and wrist splinting for 3 to 6 months. If there is no improvement, surgical decompression may be indicated.

Median Neuropathy

Injury to the median nerve proximal to the elbow results in loss of sensation of the palmar surface of the thumb and the index and middle fingers.⁸⁴ Motor deficits include loss of forearm pronation, wrist and digit flexion, and thumb abduction. Chronic deficits result in thenar muscle atrophy.

There are a number of median nerve syndromes that occur in the elbow and forearm, only a few of which will be discussed here.

Pronator Syndrome

Pronator syndrome is a compression neuropathy of the median nerve at any one of several sites at the elbow and proximal forearm. Sites adjacent to the pronator teres muscle include (1) beneath the bicipital aponeurosis and (2) as the nerve passes between the humeral and ulnar heads.^81,84,90 This syndrome is seen in athletes whose sports require repetitive forceful pronation and gripping.

Several clinical indicators help confirm the diagnosis of a pronator syndrome. Pain with resisted pronation when the elbow is extended and the wrist flexed suggests localization of compression within the pronator teres. One of the most sensitive tests for pronator syndrome is when deep, direct palpation of the proximal forearm over the pronator teres reproduces symptoms.

This condition may be confused with carpal tunnel syndrome as both will cause numbness, paresthesias, and muscle weakness in the median nerve distribution.⁹¹ Some noted differences include a lack of nocturnal symptoms in pronator syndrome and a negative Tinel sign.

The workup should include radiographs and electrodiagnostic studies. Initial management is rest, anti-inflammatory drugs, and occasional splinting. Surgical treatment is only necessary when the symptoms are refractory for 6 months or more.⁹²

Anterior Interosseous Nerve Syndrome

Anterior interosseous nerve syndrome is uncommon and may present clinically with vague forearm pain or pain with activity.⁹⁰ The anterior interosseous nerve is a branch of the median nerve. In contrast to pronator syndrome, pain is elicited with resisted flexion of the long finger. Muscle atrophy without sensory deficits is found late. Motor weakness usually begins within a day after the pain is noted.

Carpal tunnel syndrome, the most common site of median nerve compression, is discussed in Chapter 12 (Wrist).

Ulnar Neuropathy

Ulnar neuropathy results in impaired adduction or abduction of the digits due to loss of motor strength to the interosseous muscles. Sensory deficits include loss of sensation to the small finger. Fixed deficits are rare, but the characteristic lesion is that of a “claw hand” with hyperextension at the metacarpophalangeal joint of the ring and small fingers with flexion at the proximal interphalangeal and distal interphalangeal joints (Fig. 14–46).

Cubital Tunnel Syndrome

Cubital tunnel syndrome is an ulnar nerve entrapment syndrome near the elbow and is the second most common compressive neuropathy in the upper extremity.^84,93 The nerve descends down the arm without branching and passes through the groove between the medial epicondyle and the olecranon. This is a potential site of compression or traction. However, the most common site of compression is 1 to 2 cm distal to the ulnar groove. At this location, the nerve passes into the cubital tunnel and between the two heads of the flexor carpi ulnaris.⁹⁴

The act of throwing is often responsible for ulnar nerve traction at the elbow in the athlete. Holding a tool in a position repetitively can lead to this entrapment, and in some cases, a ganglion causes compression of the nerve.^95–97

Patients classically present with medial elbow and forearm pain and paresthesias radiating into the ring and little fingers. Motor findings are subtle and ulnar neuropathy at the elbow is difficult to differentiate from neuropathy caused elsewhere. The elbow flexion test, in which pain is elicited with elbow flexion, may be useful.⁹⁸

Nonoperative treatment consists of rest, ice, anti-inflammatory medications, and night splinting with the elbow at 45 degrees of flexion and the forearm in the neutral position. An elbow pad can prevent injury to the nerve in athletes. The natural history of this disorder is spontaneous resolution in as many as half the cases.⁹⁹ If this treatment regimen is unsuccessful, or testing demonstrates a significant neuropathy, surgery may be indicated.