Elbow dislocations

Cite this article as:
Becky Platt. Elbow dislocations, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.28344

You are called to assess 14-year old Oliver who has presented to your ED by ambulance with an elbow injury.  He dived to make a save while playing football and landed on his outstretched hand.  He reports feeling a click in his elbow, followed by excruciating pain.  He was given methyoxyflurane in the ambulance which has helped. 

Assessment of any child and examination of their elbow should be approached in an age-appropriate and systematic way.  In addition to examining for bony tenderness, vascular and neurological status should be tested.

Oliver’s elbow looks significantly swollen, deformed and bruised.  You feel for a radial pulse – it’s there – and  undertake a neurovascular assessment, which is intact.  You prescribe him some intranasal fentanyl and order AP and lateral x-Rays of his elbow.

The elbow is an incredibly stable joint due to the way the humerus and ulna articulate (giving anterior-posterior and varus-valgus stability), strengthened by the medial and lateral collateral ligaments and the joint capsule.  Muscles and tendons further strengthen this ring.  A significant amount of force is needed to dislocate the elbow. 

Traumatic dislocation of the elbow is rare in the paediatric population comprising only 3-6% of all childhood elbow injuries, but the most common large joint dislocation (Lieber et al., 2012).  It is usually the result of a fall onto an outstretched hand, often with a large amount of force involved.  

Clinically, it is obvious that there is significant injury around the elbow; this is not something you will miss or be tempted not to x-ray.  Displaced supracondylar fractures can sometimes be confused with elbow dislocation as both present with a grossly swollen elbow and significant pain.  A quick and easy way to distinguish the two clinically is to palpate for the equilateral triangle formed by the olecranon and the two epicondyles: this is lost in elbow dislocation as the humerus creates a fullness in the antecubital fossa. There is no need to check movements in a deformed elbow but be sure to undertake a neurovascular assessment as a priority.  

The easiest way to classify simple elbow dislocations is by describing the direction of ulna dislocation in relation to the distal humerus.

Classification of elbow dislocations

90% of paediatric elbow dislocations are postero-lateral with the radiographic appearance as below:

But beware: elbow dislocations rarely present in isolation.  They often coexist with other elbow injuries. Associated fractures are likely to occur prior to closure of the epiphyses; when they are closed, collateral ligaments are likely to be ruptured (Lieber et al., 2012). The most common associated fracture is a medial epicondyle avulsion which can become incarcerated in the joint – scrutinize the elbow x-rays for associated fractures. This illustrates the importance of knowing CRITOE.

Elbow dislocation with medial epicondyl avulsion from Orthobullets.com. The white arrow points to the avulsed medial epicondyl while the red arrow shows where it has been avulsed from.

Oliver returns from x-ray and you review his films. You note the posterior dislocation but cannot see any associated fractures on Oliver’s films. You contact your orthopaedic team for further assistance.

Management

Many elbow dislocations reductions can be carried out in the emergency department with adequate muscular relaxation and appropriate analgesia.  A reasonable amount of force is often required to achieve reduction using traction on the forearm with counter-traction around the elbow.  This should be carried out or supervised by a clinician experienced in the procedure. 

Common pitfalls in elbow reduction

Be very careful to conduct a thorough neurovascular assessment before attempting reduction. The brachial artery and median nerve may become stretched over the displaced proximal ulna and ulnar nerve can become damaged when medial epicondyle avulsions complicate elbow dislocations. If a deficit is found after reduction you need to know whether it was present before you attempted relocation…

And if you can’t reduce the dislocation go back and have another look at the x-ray – it could be due to an avulsed medial epicondyle in the joint. Any elbow dislocation with an incarcerated piece of avulsed bone in the joint must be reduced in theatre and not in the ED.

Complications

Possible complications following elbow dislocation include residual limitation of the range of movement, recurrent instability, neurovascular injury, avascular necrosis of the epiphyses and degenerative arthritis. Early diagnosis and stable reduction, with fixation of concomitant fractures if necessary, are generally associated with better outcomes.  For the Emergency department clinician, it is therefore critical that children with this injury are assessed and managed with the minimum possible delay, ensuring that associated fractures are recognised and managed appropriately.

After sedation with ketamine, Oliver’s elbow is reduced in the department with a satisfying clunk signifying reduction.  His elbow is put through a full range of movement to test joint stability and an above elbow backslab applied.  You order repeat x-Rays to evaluate the position and to check for the joint spacing and any fracture fragments within the joint as this would require surgical intervention.  The post-reduction films are good and Oliver’s neurovascular assessment remains normal and he leaves your ED with a follow-up appointment in fracture clinic in a week’s time.

References

Cadogan, M. (2019) Elbow Dislocation https://lifeinthefastlane.com/elbow-dislocation/

Edgington, J. (2018) Elbow Dislocation – Pediatric.  

https://www.orthobullets.com/pediatrics/4013/elbow-dislocation–pediatric

Lieber, J., Zundel, S., Luithle, T., Fuchs, J., & Kirschner, H-J. (2012) Acute traumatic posterior elbow dislocation in children.  Journal of Pediatric Orthopaedics B. 21(5) 474-481

Rasool, M. N. (2004). Dislocations of the elbow in children. The Journal of Bone and Joint Surgery, 86, 1050–1058. 

Sibenlist, S. & Biberthaler, P. (2019) Simple Elbow Dislocations in Biberthaler, P., Sibenlist, S. & Waddell, J.P. Acute Elbow Trauma.  Fractures and dislocation injuries (eBook).  Springer

Sofu, H., Gursu, S., Camurcu, Y., Yildirim, T., & Sahin, V. (2016). Pure elbow dislocation in the paediatric age group. International Orthopaedics, 40(3), 541–545

Olecranon fractures

Cite this article as:
Becky Platt. Olecranon fractures, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.21080

14-year old Noah was rocking on his chair while daydreaming his way through a maths lesson this morning… and fell off.  He reports that he landed directly on his left elbow and that it has been painful throughout the day.  He attends your ED this afternoon with his unamused mother.

Assessment of any child and examination of their elbow should be approached in an age-appropriate and systematic way.  In addition to examining for bony tenderness, vascular and neurological status should be tested.

You ensure Noah has been given analgesia before examining him.  His pain score is 5 and he seems comfortable after paracetamol and ibuprofen when his arm is resting.  His elbow is notably bruised and swollen. He is particularly tender over the olecranon and any movement is painful.  His neurovascular status is normal with good radial and ulnar pulses, normal sensation in the radial, ulnar and median nerve distributions and as he’s able to make the rock, paper, scissors and ok hand signs, you’re happy he has full motor function.  You order AP and lateral films of his elbow and pop him in a broad arm sling for comfort before sending him round for his x-rays.

Epidemiology and mechanism of injury

Olecranon fractures in children are rare, comprising around 5% of elbow fractures. Compare this with supracondylar fractures which comprise over half of all elbow fractures in the paediatric population. Olecranon fractures may result from a fall onto an outstretched hand (FOOSH), direct trauma or, occasionally, a stress fracture from repetitive throwing motion in athletes.

They can be classified according to the Mayo classification.

Examination findings

In addition to pain, there will almost certainly be generalised swelling around the elbow, usually with visible evidence of trauma, such as bruising or abrasion, over the olecranon process.  Point tenderness over the olecranon is often a feature, but the degree of swelling can sometimes make this difficult to appreciate.  Inability to fully extend the elbow is common, and pain on extension, supination and pronation is expected.  In those with comminuted or significantly displaced fractures it may be possible to feel crepitus over the olecranon.

Radiology

Interpreting children’s elbow x-rays can be mind boggling. Epiphyses ossify at different rates and so it can be easy to confuse a normal olecranon epiphysis with a fracture.  The olecranon epiphysis normally appears around 9 years and fuses at 15-17 years.   Be sure to refer to the CRITOE rules and if you’re not sure whether you’re seeing a normal epiphysis or a fracture, seek senior advice.  The olecranon can be best assessed on the lateral film.

This x-ray shows a normal olecranon epiphysis:

Case courtesy of Dr Jeremy Jones, Radiopaedia.org. From the case rID: 26814

Some olecranon fractures are obvious…

…but some can be incredibly subtle as illustrated in this series from Radiology Assistant:

Some olecranon fractures may only be visible on one view.  This may be the AP or the lateral.  The below elbow x-rays show a transverse olecranon fracture visible on the AP view only (arrow).  Note the raised anterior and posterior fat pads on the lateral view.  And an extra bonus point to those who spotted the subtle radial neck fracture.

Management

The majority of olecranon fractures (around 80%) are either undisplaced or minimally displaced (less than 2mm); these can be managed conservatively with an above elbow back-slab with good functional outcome.

Minimally displaced (<2mm) fracture in a 7 year old, requiring conservative management only. Case courtesy of Dr Jeremy Jones, Radiopaedia.org. From the case rID: 23650

Complications

In children with a displaced olecranon fracture, there is risk of complications including delayed or non-union, ongoing elbow stiffness and impaired function.  Refer any child who has an olecranon fracture with these features as they’re likely to require surgical intervention:

  • >2-4mm displacement
  • angulation of >30°
  • intra-articular involvement
  • extensor mechanism disruption
  • instability on extension
  • comminution

Olecranon fracture with >30 degrees of displacement, requiring surgical fixation. From Orthobullets.com.

The practitioner seeing injured children in the ED must be aware of the potential for these.  Displaced olecranon fractures can cause growth disturbances resulting in fixed flexion deformity of the elbow joint and associated morbidity into adulthood.

The ulnar nerve is particularly at risk of injury with olecranon fracture. Ensure you carry out a thorough neurovascular assessment, in particular checking sensation over the little finger and that the small muscles of the hand are functioning normally (the “scissors” sign).

A significant proportion of olecranon fractures are associated with concomitant injury, including radial neck fracture and /or supracondylar fracture and any co-existing injury is prognostic for poorer outcome.  When interpreting the x-ray, it is important therefore to have a systematic approach.

Bullets of wisdom 

  • Don’t confuse an unfused olecranon epiphysis with a fracture
  • But don’t forget that olecranon fractures can be subtle – maintain a high index of suspicion in children with direct trauma and inability to extend their elbow
  • Olecranon fractures are sometimes only visible on one view and this can be the lateral or the AP
  • Displaced fractures can have devastating consequences and must be referred to orthopaedics as they may need surgical intervention
  • Document neurovascular status and be sure to check ulnar nerve function
  • And look for a concomitant radial neck or supracondylar fracture

Noah returns from X-Ray and you review his films. He has a posterior fat pad sign and on closer scrutiny you spot an intra-articular fracture of the olecranon. You recognise that this type of fracture can be associated with complications and refer him to the orthopaedic team.  You ensure that his pain score and neurovascular status are being assessed regularly.

 

References

Cabanela M.E. & Morrey B.F. (1993) The Elbow and Its Disorders. 2nd ed. Philadelphia, PA, USA: WB Saunders cited in Sullivan, C. W., & Desai, K. (2019). Classifications in Brief: Mayo Classification of Olecranon Fractures. Clinical Orthopaedics and Related Research, 477(4), 908–910.

Caterini, R., Farsetti, P., DʼArrigo, C., & Ippolito, E. (2002). Fractures of the Olecranon in Children. Long-Term Follow-Up of 39 Cases. Journal of Pediatric Orthopaedics B, 11(4), 320–328.

Corradin, M., Marengo, L., Andreacchio, A., Paonessa, M., Giacometti, V., Samba, A., … Canavese, F. (2016). Outcome of isolated olecranon fractures in skeletally immature patients: comparison of open reduction and tension band wiring fixation versus closed reduction and percutaneous screw fixation. European Journal of Orthopaedic Surgery and Traumatology, 26(5), 469–476.

Degnan, A. J., Ho-Fung, V. M., Nguyen, J. C., Barrera, C. A., Lawrence, J. T. R., & Kaplan, S. L. (2019). Proximal radius fractures in children: evaluation of associated elbow fractures. Pediatric Radiology, 1–8.

Edgington, J. & Andras, L. (2019) Olecranon fractures – pediatric https://www.orthobullets.com/pediatrics/4010/olecranon-fractures–pediatric?expandLeftMenu=true

Hill, C. E., & Cooke, S. (2017). Common Paediatric Elbow Injuries. Open Orthopaedics Journal, 11, 1380–1393.

Kraus, R. (2014). The pediatric vs. the adolescent elbow. Some insight into age-specific treatment. European Journal of Trauma and Emergency Surgery, 40(1), 15–22.

Nicholson, L. T., & Skaggs, D. L. (2019). Proximal Radius Fractures in Children. The Journal of the American Academy of Orthopaedic Surgeons, 00(00), 1–11.

Pace, A., Gibson, A., Al-Mousawi, A., & Matthews, S. J. (2005). Distal humerus lateral condyle mass fracture and olecranon fracture in a 4-year-old female – Review of literature. Injury Extra, 36(9), 368–372.

Perkins, C. A., Busch, M. T., Christino, M. A., Axelrod, J., Devito, D. P., Fabregas, J. A., … Willimon, S. . (2018). Olecranon fractures in children and adolescents: outcomes based on fracture fixation. Journal of Children’s Orthopaedics, 12, 497–501.

Rath, N. K., Carpenter, E. C., Ortho, F., & Thomas, D. P. (2011). Traumatic Pediatric Olecranon Injury. A Report of Suture Fixation and Review of the Literature. Pediatric Emergency Care, 27(12), 1167–1169.

Medial epicondylar fractures of the humerus

Cite this article as:
Lisa Dunlop. Medial epicondylar fractures of the humerus, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.21036

In this section, we will mainly discuss medial epicondylar fractures. Medial condylar fractures are a rare pattern of fracture and managed in a similar manner to lateral condylar fractures. It is important to differentiate between medial condylar and epicondylar fractures. Condylar fractures are intra-articular and require urgent open reduction and internal fixation.

Lateral condylar fractures of the humerus

Cite this article as:
Lisa Dunlop. Lateral condylar fractures of the humerus, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.21030

Six-year-old William was playing hopscotch in the playground but fell, landing on his left outstretched hand. Afterwards, he complained of left elbow pain and was taken to the local Emergency Department. He was told that he had a lateral condylar fracture of the humerus…

Epidemiology 

This is a relatively common fracture in the paediatric population and occurs mainly in children below the age of 7 years old, with a mean age of 6. It accounts for approximately 10-20% of paediatric elbow fractures and is the second most common intra-articular fracture.

History 

The most common aetiology for this fracture is a fall onto an outstretched hand. The patient will complain of pain to the lateral aspect of the elbow. The level of pain may be low in minimally displaced fractures.

Examination

Have a look at our post on elbow examination for tips on how to do a full assessment of a child’s elbow.

Inspection of the joint will reveal an elbow with swelling to the lateral aspect. There is usually minimal deformity. Bruising may indicate a brachioradialis tear and therefore likely instability. Tenderness is usually limited to the lateral aspect and crepitus may be palpated on movement. Wrist flexion and extension may reproduce the pain.

It is important to carefully examine the joint below and above the injured area. Don’t forget to examine the rest of the child for other injuries.

Remember to be suspicious of non-accidental injury in cases where there are inconsistencies in the history and injury type.

Investigations

AP and lateral x-rays of the elbow are required. Oblique views can be valuable if no fracture is seen on lateral or AP views but clinical suspicion remains. This is where your knowledge of the ossification centres comes into play (for detail on this see CRITOE). The ossification centres appear on x-rays in the order: Capitellum, Radial head, Internal epicondyle, Trochlea, Olecranon and the External epicondyle, also known as the lateral condyle. The lateral epicondyle appears at the age of 8-12 years old and fuses at age 12-14 years old.

The paediatric elbow is largely cartilaginous. Lateral condylar fractures often only affect the cartilaginous part of the humerus. As cartilage is not radiopaque, the true extent of the fracture is often not fully understood when looking at the x-ray.

The presence of anterior and posterior fat pads may often be the only indication that a fracture is present.

The most commonly associated fracture is the ipsilateral elbow dislocation (usually posterolaterally) and ipsilateral humeral fractures (most commonly the olecranon). Ensure you obtain radiographs for other suspected fractures.

 Lateral condyle fractures can be classified depending on their x-ray appearances.

Classification

There are several different classification methods. The most common classifications as below.

Milch Classification
Type 1The fracture line is lateral to the trochlear groove… not into the humero-ulnar joint
Type 2The fracture line is medial to the trochlear groove and is, therefore, a fracture-dislocation and unstable.
Milch Classification
Jakob Classification
Stage 1<2mm displacement, which indicates intact cartilaginous hinge 
Stage 22-4mm of displacement 
Stage 3>4mm displacement with rotation of the fragment 
Jakob Classification

Immediate treatment in the ED

Provide immediate adequate analgesia to the child prior to any examination or investigation.

If the fracture is open, conservatively manage the wound, consider tetanus status and antibiotics.

Keep the child nil by mouth as they may need urgent surgery.

Treatment following imaging

Treatment depends on the degree of displacement of the fracture.

Due to the high complication rate of these fractures, all lateral condylar fractures should be referred for to the on-call orthopaedic team while in the Emergency Department.

Jakob classificationTreatment optionFollow up
Stage 1 (<2mm of displacement)Conservative management with immobilisation with above elbow cast to 90 degrees.Weekly imaging in fracture clinic with the cast in place for 4-6 weeks.
Stage 2 and 3 (> 2mm with or without rotation)These all must go to theatre and have closed reduction with percutaneous pinning or open reduction with screw fixation.3-6 weeks in above-elbow cast and orthopaedic follow up.

Areas of controversy

Serial radiographs are often recommended in the management of conservative management minimally or undisplaced lateral condylar fractures. A systematic review by Tan et al 2018 found that serial X-rays have no clinical significance. However, if the 1 week up x-ray is not satisfactory, this should be followed up appropriately under the patient’s treating orthopaedic team.

Potential complications

This type of fracture is associated with a high rate of complications, which usually develop later, during the healing process.

The reduction must be accurate. If there is malunion, the fragment does not adequately unite or the epiphyseal plate is damaged then complications may occur:

  • Stiffness is the most common complication, usually fully resolving by 48 weeks.
  • Delayed union occurs if the fracture has not healed after 6 weeks. This usually occurs if the fracture visible at 2 weeks.
  • Non-union is more likely when delayed union occurs.
  • Cubitus valgus deformity occurs with lateral physeal growth arrest.
  • Delayed “tardy ulnar palsy” may develop as the child grows and the ulnar nerve is stretched across the elbow with valgus deformity.
  • Avascular necrosis may develop 1-3 years after the fracture.
Image from wikimedia.org

Do not miss bits

Lateral condylar fractures of the humerus can present with minimal pain or deformity and can be missed (16.6% misdiagnosed as presented by Tan et al 20181). Due to the high rate of complication, it is important that we do not miss these fractures.

William was found to have an isolated Jakob stage 3 type lateral condylar fracture and was taken to theatre that evening. Open reduction was required, and internal screw fixation secured the fragment. His cast was removed 4 weeks after and his joint mobility continues to improve.

References

Bowden G, McNally MA, Thomas RYW, Gibson A. 2013. Oxford Handbook of Orthopaedics and Trauma, Oxford Medical Publications. Page 564-5

Dandy DJ, Edwards DJ, 2003. Essential Orthopaedics and Trauma, Fourth Edition, Churchill Livingstone, page 197.

Raby N, Berman L, Morley S, de Lacey G. 2015. Accident and Emergency Radiology: A survival Guide Third Edition, Sauders Elsevier page 106-110.

Shaath k, Souder C, Skaggs D. 2019. Orthobullets, Lateral Condyle Fracture – Pediatric Accessed 06/04/2019 https://www.orthobullets.com/pediatrics/4009/lateral-condyle-fracture–pediatric

Tan SHS, Dartnell J, Lim AKS, Hui JH. Paediatric lateral condyle fractures: a systematic review. Arch Orthop Trauma Surg. 2018 Jun;138(6):809-817. doi: 10.1007/s00402-018-2920-2. Epub 2018 Mar 24. Review. PubMed PMID: 29574555.

Monteggia fracture dislocations

Cite this article as:
Rie Yoshida. Monteggia fracture dislocations, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.21141

Emiko is an 8-year-old girl who presents to the ED with a swollen and painful left arm. She is a keen mixed martial arts enthusiast and has suffered a direct blow to the arm whilst practising earlier today. On examination, her left proximal forearm and elbow joint are swollen and tender. She has limited movement of her elbow joint. The arm is neurovascularly intact.

Elbow examination

Cite this article as:
Becky Platt. Elbow examination, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.19777

2-year-old Alfie presents to the Emergency department having sustained an injury jumping on the sofa and falling off at home an hour ago.  His older sister says she thinks he put his right hand out as he fell, landing on the carpet.  Alfie’s mum gave him a dose of paracetamol after the injury and brought him straight to the ED because his elbow looked so swollen.  Alfie looks pale and tearful.