Elbow Injuries



Elbow x-rays

When reviewing elbow x-ray please check:

  1. Fat Pads (see white arrows in left image)
  2. Anterior humeral line (throu' ant / mid 1/3 capitellum)
  3. Radiocapitellar line (Radial shaft alignment with capitellum in ALL views)
  4. C R I T O L capitellum, radial head, internal epicondyle, trochlea, olecranon, lateral epicondyle

Please see upper limb x-rays for more


Dislocation of the elbow

  • Needs urgent reduction. 
  • Call senior ED staff before admit ortho
  • Document neurovascular status

Fractured olecranon

  • Admit ortho for ORIF (wires)

"Pulled Elbow"

  • Child (1 to 6 years). Hx of traction injury, not using arm (often kept "limp" in extension and pronated - almost "waiters tip")
  • No signs clavicle, shoulder or wrist injury
  • Poorly localised elbow tenderness. Pain on elbow movements especially rotation
  • Pronation with or without elbow flexion is the first line method of reduction for pulled elbows [BestBets]
  • Listen or feel for click. Leave child for a few minutes and then observe function
  • If no recovery consider X-ray and if normal X-ray, ask to return after one day if not using arm normally

Supracondylar fracture of humerus#

  • In all children check (1) Fat pads (2) Ant humeral line (3) Radiocaptetellar line (4) CRITOL (please see x-rays section)
  • Check and record neurovascular status
  • Popliteal art. damage, or Ant Interosseous (median) Nerve - Ok sign?
  • Simple undisplaced fractures may be placed in a sling or full length POP (90°) depending on comfort
  • Please discuss each case with your ED aenior
  • If necessary admit orthopaedics
Supracondylar fracture Supracondylar fracture

Supracondylar #

Gartland classification

I : undisplaced or minimally displaced.

II : displaced but with intact cortex.

II a: posterior angulation with intact posterior cortex; anterior humeral line does not intersect capitellum.

III : completely displaced.


# neck/head of radius

  • Check radial pulse
  • Assume an intra-articular (or supracondylar) if mal-alignment or effusion seen
  • Treat fractured head of radius with analgesia and a broad arm sling
  • If gross displacement / comminution refer to on-call Orthopaedic Team
  • Therapeutic aspiration is not our routine practice [BestBets]
  • Otherwise refer to the next Fracture Clinic. Referral form)
  • Repeat radiography is not needed for traumatic elbow effusions with no fracture on initial x-ray [BestBets]

Radial Head / Neck # Mason Johnston Classif.

I - Nondisplaced

II - Minimally displaced with depression, angulation and impaction

III - Comminuted and displaced

IV - Radial head # with dislocation of the elbow


Lateral epicondyle

  • Usually FOOSH
  • Record neurovascular findings
  • Check C R I T O L, lines and fat pads
  • Typically Salter Harris iv
  • Often subtle x-ray findings, sometimes just positve fat pads
  • Consider oblique or X-ray in children
  • Refer Ortho. These fractures have poor prognosis (mal/non union). Undislaced fractures may be treated (after ortho consult) in a above-elbow PoP (90° flex) and fracture clinic. Any rotation or displacement (esp if >2mm) need surgery (ORIF) today
  • High incidence long term valgus deformity with delayed ulnar N. palsy
Lateral Epicondyle fracture Lateral Epicondyle fracture

Medial epicondyle

  • Usually pull off # with valgus stress on elbow (beware dislocation)
  • May not have fat pad sign (extra-articular)
  • Beware intra-articular condylar # (all need ORIF) rather than epicondyle #
  • Surgery now if >15 mm displacement, med epicondule in joint (easily missed)
  • Record neurovascular examination findings
  • Always check C R I T O L, Ant Humeral line, Radiocapitellar line and fat pads
  • Minimal displaced medial epicondylar # = PoP backslab (90° flexion) and fracture clinic follow up
  • Displaced #, elbow dislocation or intra-articular condylar # = ortho referral now for ORIF
Medial Epicondyle fracture Medial Epicondyle fracture

Dislocated head of radius (abnormal radiocapitellar line)

  • Radiocapitellar line should be good in all x-rays
  • Often with # of ulnar shaft (Monteggia fracture-dislocation)
  • X-rays of the whole forearm are required
  • Beware neurovascular (particularly radial N motor fxn)
  • Admit ortho for ORIF
Radial head dislocation Radial head dislocation

Forearm

Fractured shaft of radius and ulna

  • Refer to on-call Orthopaedic Team
  • MUGAR (Monteggia - Ulna #, Galeazzi - Radial #)

Dislocated head of ulna

  • Usually associated with a fracture of the radial shaft (Galeazzi fracture-dislocation - image right) and X-rays of the whole forearm are required for diagnosis
  • Refer to on-call Orthopaedic Team
Galeazzi 1

Content by Dr Íomhar O' Sullivan. Last review Dr ÍOS 8/05/24.