Elbow Fractures Overview

Etiology

Fracture patterns vary with patient age and mechanism of injury. The most common cause is a FOOSH, although direct trauma to the elbow can also result in a fracture. Playground injuries, particularly those involving monkey bars, are frequent sources of pediatric elbow trauma.

Supracondylar fractures may present as either extension- or flexion-type injuries, depending on the direction of distal fragment displacement. Extension-type fractures typically result from a FOOSH injury, while flexion-type fractures commonly arise from a direct blow to the posterior olecranon. Radial head fractures commonly occur following a FOOSH injury with the forearm in pronation.[19]

Coronoid process fractures are often caused by axial compression transmitted through the trochlea. Transolecranon fracture-dislocation is a high-energy injury caused by direct trauma to the proximal dorsal forearm. This mechanism results in anterior displacement of the forearm relative to the distal humerus, typically with a comminuted olecranon fracture.[20]

Olecranon fracture types arise from different mechanisms. Comminuted fractures typically follow a direct fall onto the elbow, whereas noncomminuted fractures are associated with FOOSH injuries.

Epidemiology

Elbow fractures account for up to 5% of all fractures, with a higher incidence in children than in adults.[21] Supracondylar fractures are the most common type in children younger than 7 years, peaking between ages 5 and 7, and occur more frequently in boys. Fracture patterns vary by age and mechanism of injury. In children, the most common types are supracondylar fractures (50% to 70%), followed by lateral condylar (17% to 34%) and medial epicondylar fractures (10%).[22] In contrast, intra-articular fractures predominate in adults.

Pathophysiology

The elbow is a complex joint with 3-dimensional mobility, permitting flexion and extension between the distal humerus and the ulna. Stability is provided by the osseous architecture, joint capsules, and surrounding ligaments. The ulnohumeral joint provides the primary restraint to static elbow stability, particularly in flexion, while the radiocapitellar joint bears the majority of axial load during extension, with load distribution varying depending on elbow position.[23][24] Common clinical findings include limited elbow extension and pain during forearm supination and pronation.

History and Physical

Elbow fractures commonly result from direct trauma or a FOOSH. Acute presentation includes sharp, localized pain in the elbow and forearm, with limited extension and discomfort during supination and pronation. Swelling and tenderness frequently obscure surface anatomy. Palpation of the radial neck, olecranon, medial and lateral epicondyles, and supracondylar region is essential to localize injury.

A systematic approach to physical examination should include inspection, palpation, assessment of ROM, and a focused neurovascular evaluation. Gross deformity may indicate significant displacement. In Monteggia fractures, the dislocated radial head may be subtle or easily missed, making the assessment of radiocapitellar alignment critical. Evaluation of the full 4-directional ROM—pronation, supination, flexion, and extension—should be performed. Preserved ROM lowers clinical suspicion for major fractures but does not exclude intra-articular injuries such as radial head or capitellum fractures.[25]

In adults, the elbow extension test may aid in ruling out a fracture. Full active extension significantly lowers, but does not eliminate, the likelihood of significant bony injury. Tenderness and swelling over the antecubital fossa may suggest a coronoid process fracture.

A comprehensive neurovascular examination is mandatory. Numbness in the forearm or hand suggests possible nerve involvement. Peripheral pulses must be palpated to assess vascular integrity.

The anterior interosseous nerve (AIN) is most frequently affected in supracondylar fractures. Assessment involves testing the flexor pollicis longus and flexor digitorum profundus by instructing the patient to form an “OK” sign. Inability to perform this maneuver indicates motor dysfunction of the AIN. Posterior interosseous nerve (PIN) integrity is evaluated through active finger extension. A warm, well-perfused hand does not rule out brachial artery injury, as distal perfusion may be maintained by collateral circulation despite complete arterial disruption. Serial neurovascular examinations should be performed to monitor for evolving compartment syndrome or delayed vascular compromise, particularly following reduction or splinting.

Regional assessment should extend beyond the elbow. Examination of the ipsilateral shoulder and wrist is necessary to exclude concurrent injuries. Coronoid fractures may coexist with complex injury patterns such as the terrible triad, which includes elbow dislocation, radial head fracture, and coronoid process involvement. Thorough clinical evaluation is essential to identify subtle or unstable fracture patterns.

In pediatric patients, growth plate injuries may be radiographically subtle, and nonverbal signs such as guarding or irritability should be carefully interpreted. Evaluation must account for open physes, cartilaginous structures, and age-specific fracture patterns.

Evaluation

Evaluation should begin with a primary survey, which includes a rapid assessment of vital signs, airway patency, adequate breathing, circulation, and control of external bleeding. This initial step aims to identify and address life-threatening conditions without delay. A focused neurovascular examination must follow, as injuries to nerves or blood vessels are common in elbow trauma.

Serial neurovascular examinations are critical throughout the course of treatment, particularly after reduction or immobilization, to detect evolving ischemia or compartment syndrome. The AIN is most frequently injured and may be evaluated by asking the patient to make an “OK” sign by flexing the thumb and index finger simultaneously to form a circle. The inability to perform this movement may indicate nerve damage. The PIN, a deep branch of the radial nerve, may be injured in Monteggia fractures. This nerve supplies the finger extensors and the supinator, and injury manifests as weakness or paralysis of thumb and finger extension. Vascular injury may involve the brachial artery, and a subset of cases may be complicated by compartment syndrome.

Initial imaging should include anteroposterior and lateral radiographs of the elbow. The anteroposterior view visualizes the medial and lateral epicondyles and their articular surfaces. The lateral view assesses the alignment of the distal humerus and proximal forearm, including the relationships of the anterior and posterior fat pads to the humerus. A systematic radiographic approach should include verification of radiocapitellar alignment on all views, as disruption may be the only indicator of a Monteggia fracture or subtle dislocation.

On lateral imaging, the anterior humeral line should intersect the middle 3rd of the capitellum, while the radiocapitellar line, drawn through the center of the radial neck, should also pass through the center of the capitellum. Disruption of these anatomic relationships suggests fracture. Although the anterior fat pad may be visible normally, elevation or displacement may indicate joint effusion or hemarthrosis. A visible posterior fat pad is always considered pathologic, particularly in the setting of a suspected supracondylar fracture.

An oblique radiographic view provides improved visualization of the radiocapitellar joint, medial epicondyle, radioulnar joint, and coronoid process. This view is especially useful for identifying subtle lateral condyle fractures and evaluating displacement. An anteroposterior view obtained with the elbow flexed to 40° may help disengage the olecranon from the olecranon fossa, improving visualization of the capitellum. The radial head should be aligned with the capitellum in all views to confirm normal radiocapitellar alignment.

A contralateral comparison radiograph may be considered in young children but is not routinely recommended. Interpreting pediatric elbow radiographs can be challenging due to the predominantly cartilaginous composition of the joint and the presence of open growth plates. Evaluation should account for the possibility of cartilaginous injuries not visible on plain radiographs. Nonverbal cues such as irritability or refusal to use the arm may be early signs of injury.

Six ossification centers surround the pediatric elbow. Familiarity with the sequence denoted by "CRITOE" is essential for identifying subtle elbow injuries in children.

• C: Capitellum
• R: Radial head
• I: Internal (medial) epicondyle
• T: Trochlea
• O: Olecranon
• E: External (lateral) epicondyle

The capitellum typically appears at approximately 1 year of age, with each successive ossification center emerging at roughly 2-year intervals, around 1, 3, 5, 7, 9, and 11 years, respectively.

CT may be necessary to determine the precise location of a fracture and assess for associated instability. Three-dimensional reconstructions enhance the evaluation of complex fracture patterns in select cases. Capitellum fractures are often difficult to detect on plain radiographs, necessitating CT for accurate visualization. Coronoid fracture fragments may appear small or poorly defined on lateral radiographs. Therefore, CT is recommended when such fractures are suspected. CT should also be considered for intra-articular fractures with questionable displacement or in cases of mechanical instability where radiographs are inconclusive. Magnetic resonance imaging can help identify occult fractures, chondral injuries, and soft tissue damage in pediatric or athletic populations.

Ultrasound has become an increasingly useful diagnostic tool for elbow fractures. Cortical disruption of bone, visible on sonography, serves as a direct indicator of fracture. A recent systematic review has demonstrated high sensitivity and specificity for ultrasound in both ruling out and confirming elbow fractures.[26] Arteriography is indicated when brachial artery injury is suspected but should not delay timely closed reduction of the fracture.

Treatment / Management

The goals of treatment are to immobilize the fracture and restore proper alignment in an acceptable anatomic position. Early identification and treatment of neurovascular injuries are essential to reduce the risk of complications. Management is guided by fracture stability and the degree of neurovascular compromise. Immediate application of forearm traction is warranted when neurovascular involvement is present, as this maneuver may restore distal pulses. Adequate analgesia must be administered without delay.

Initial management should include prompt immobilization using a posterior long-arm splint, elevation of the limb, and frequent neurovascular assessments to monitor for evolving ischemia or compartment syndrome. Serial examinations are particularly important after reduction or splint application.

Interventions for Supracondylar Fractures

Nondisplaced supracondylar fractures do not require operative intervention. Initial treatment consists of immobilization using a long-arm posterior splint. The elbow must be flexed at 90° while the forearm is positioned neutrally. The splint is later replaced by a cast once the swelling has subsided. A follow-up radiograph after 1 week is necessary to confirm appropriate alignment and monitor healing. Cast removal typically occurs after 3 to 4 weeks.

Displaced supracondylar fractures require surgical intervention. Angulation exceeding 20° warrants orthopedic evaluation and fracture reduction under sedation and analgesia. Neurovascular status must be continuously monitored.

Closed reduction with percutaneous pinning is a standard technique in managing displaced fractures. Bone fragments are realigned through closed reduction and stabilized with 2 lateral metal pins. Three pins may be required in the presence of severe displacement or a floating distal segment. The fixation is reinforced with a splint or cast, and both the pins and immobilization device are removed once adequate healing is observed in the ensuing weeks.

Open reduction with internal fixation (ORIF) is indicated in unstable supracondylar fractures. A 2-pin lateral-entry configuration is frequently employed as the primary method of percutaneous stabilization.[27] Indications for open reduction include failure of closed reduction, vascular insufficiency suggesting possible entrapment of the brachial artery, and the presence of an open fracture. Hospital admission may be necessary to monitor neurovascular function, particularly in cases of displaced fractures or extensive soft tissue swelling.(B2)

Ongoing follow-up should assess for complications such as malunion, nerve injury, and restricted ROM. Delayed or missed diagnoses may increase the risk of permanent dysfunction.

Lateral Condyle Fracture Management

Management of lateral condyle fractures is similar to that of supracondylar fractures but typically requires a longer duration of immobilization, often up to 6 weeks. Close radiographic monitoring is essential due to the high risk of secondary displacement during healing. Monitoring should include repeat imaging within the first 7 to 10 days, as even initially nondisplaced fractures may undergo progressive displacement over time.

Medial Epicondyle Fracture Treatment

Treatment follows principles similar to those for supracondylar fractures but involves a slightly different fixation approach. Instead of percutaneous pinning, small screws are used to secure the bone fragments. Consequently, the recovery period is shorter, and immobilization with a splint or cast is generally required for only 1 to 2 weeks (see Image. Rose and Welch Splints).

Interventions for Radial Head and Neck Fractures

The extent of fracture displacement determines the treatment strategy. When radial head displacement is less than 30°, immobilization with a collar is sufficient, and closed reduction is not necessary. If displacement exceeds 30°, closed reduction is required, and percutaneous pinning using a Kirschner wire is performed if reduction is unsuccessful. Excessive manipulation should be avoided in pediatric cases to reduce the risk of growth plate disturbance.

Therapeutic Approaches for Olecranon Fractures

Nondisplaced olecranon fractures may be treated conservatively using orthotic immobilization with the elbow flexed at 90°. Displaced fractures warrant ORIF to restore articular congruity. Care must be taken due to the proximity of the ulnar nerve, which lies just medial to the olecranon and is at risk of injury.

Coronoid Fracture Management

Type I coronoid fractures may be managed conservatively without surgery. In contrast, types II and III typically require operative intervention with ORIF to restore elbow stability and prevent recurrent dislocation.

Transolecranon Fracture-Dislocation Treatment

This injury may present in 1 of 2 forms: simple (type I) or comminuted (type II). Both require surgical stabilization due to the disruption of the ulnohumeral articulation.

Interventions for Monteggia Fractures

Treatment of Monteggia fractures is influenced by patient age and fracture severity. In pediatric patients, conservative treatment using a long-arm cast in supination is often sufficient following acceptable closed reduction. Urgent ORIF is typically recommended in adults due to the higher risk of persistent instability and malalignment. Radiocapitellar alignment must be confirmed postreduction, as persistent dislocation or subluxation of the radial head can lead to long-term dysfunction.

Differential Diagnosis

The differential diagnosis for elbow pain includes several nonfracture conditions. Avulsion injuries may present with localized tenderness and limited motion. Olecranon bursitis causes swelling and pain, especially with pressure. Elbow dislocation can resemble a fracture and requires prompt recognition. Ligamentous sprains and tendinopathies, such as epicondylitis, should also be considered. Accurate diagnosis depends on clinical assessment and imaging. In young children, clinicians should also consider nonaccidental trauma when the history is inconsistent, even in the absence of fractures.

Prognosis

The prognosis for most patients with supracondylar fractures is generally favorable. However, outcomes tend to worsen with increasing fracture severity. Traumatic nerve injuries are typically transient and often resolve spontaneously.[28]

Complications

The 2 broad categories of complications most commonly associated with supracondylar humerus fractures are malunion and neurovascular injury. Several nerves and vascular structures lie in close proximity to the elbow, increasing the risk of compromise. The brachial artery bifurcates at the level of the radial neck into the radial and ulnar arteries, with the median nerve running closely adjacent. The ulnar nerve is particularly vulnerable at the medial epicondyle, while the PIN encircles the lateral neck of the radial head.

Neuropraxia, a temporary nerve injury, is the most frequent neurologic complication and typically resolves within 6 to 12 weeks. Nerve injury occurs in approximately 11% of supracondylar fractures, with the AIN most frequently affected, followed by the radial, median, and ulnar nerves.[29][30]

The anterior interosseous branch of the median nerve may be injured in extension-type fractures, often due to entrapment in surrounding muscle or fibrous tissue following anterior displacement of a proximal humeral fragment. This deficit may be assessed by testing flexion at the distal interphalangeal joint of the index finger. Posteromedial displacement may involve the radial nerve, while posterolateral displacement may affect the median nerve.

Flexion-type supracondylar fractures may involve the ulnar nerve, usually at the level of the medial epicondyle, due to posterior displacement of the proximal fragment (see Image. Elbow Fracture on Lateral Radiography). Motor testing reliably identifies AIN injury through the inability to form an “OK” sign using the thumb and index finger, indicating impairment of flexion at their distal interphalangeal joints. The PIN is at risk due to its anatomical course around the lateral radial neck.[31]

Vascular injury is another significant concern. Displacement of a supracondylar fracture may damage the brachial artery.[32] Even when the hand appears pink and well-perfused, vascular injury should still be suspected in the absence of a palpable radial pulse. Partial transection of the vessel may explain this phenomenon.

Compartment syndrome is a potential complication and must be identified early. An absent radial pulse warrants urgent evaluation. A Volkmann contracture may develop due to ischemic injury of the forearm resulting from brachial artery compromise. This ischemic injury may present with an inability to open the hand in children, pain with passive extension of the fingers, forearm tenderness, and absence of a radial pulse. Prompt recognition through careful neurovascular assessment is essential to prevent irreversible damage.

Malunion frequently complicates supracondylar fractures and can result in deformities such as cubitus valgus or cubitus varus. Loss of the carrying angle may lead to cubitus varus, also referred to as a “gunstock” deformity. Nonunion is more commonly associated with lateral condylar fractures, which often require revision surgery. Monteggia fracture-dislocation also carries an elevated risk of ulnar nonunion.[33]

Fractures around the elbow are also well known for resulting in joint stiffness. Early initiation of physical therapy is critical to preserving the ROM and optimizing functional recovery.