Trauma - Elbow Injuries

Elbow x-rays

When reviewing elbow x-ray please check:

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

Please see upper limb x-rays for more

Child (1 to 6 years). History 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, review (ED Clinic) after one day if not using arm normally

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 duty doctor
If necessary refer to on-call Orthopaedic Team

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.

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]

I - Nondisplaced

II - Minimally displaced with depression, angulation and impaction

III - Comminuted and displaced

IV - Radial head # with dislocation of the elbow

Usually FOOSH
Record neurovascular examination findings
Always check C R I T O L, Ant Humeral line, Radiocapitellar line and fat pads
Typically Salter Harris iv
Often subtle x-ray findings, sometimes just positve ant/post fat pads
Consider oblique or X-ray of opposite elbow for comparison in children
Refer to on-call Orthopaedic Team. 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

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

Radiocapitellar line should be good in all (even oblique) x-rays views
Often associated with a fracture of the ulnar shaft (Monteggia fracture-dislocation)
X-rays of the whole forearm are required for diagnosis
Beware neurovascular compromise (particularly radial N motor fxn)
Refer to on-call Orthopaedic Team for ORIF today

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