Elbow trauma is a common entity in the acute care setting. In general, these injuries encompass a vast array of injury patterns from mild soft tissue injuries and contusions to complex osseoligamentous injury patterns and terrible triad injuries. In the adult patient, most of these acute injuries occur secondary to high energy mechanisms such as falls from height or motor vehicle accidents (MVAs). Elderly patients, however, are at risk for elbow injuries and traumatic fractures following even low-energy falls. The latter occurs secondary to a multitude of factors, including deconditioning, decreased agility and balance, poor vision, decreased muscle mass, and osteopenia or osteoporosis.
The elbow joint is one of the most complex joints in the human body, comprised of three distinct articulations: ulnohumeral, radiohumeral, and proximal radioulnar joints. The anterior aspect of the proximal ulna (i.e., the trochlear notch or semilunar notch) articulates with the trochlea of the distal humerus on the medial side of the elbow joint. The capitellum, a distinct ossification center located at the lateral distal humerus, articulates with the radial head.
The radial neck and the proximal radial metaphyseal region includes the radial tuberosity, the site of attachment of the distal biceps tendon. The ulnar collateral ligament (UCL) and lateral collateral ligament (LCL) complex play an important role in stabilizing the joint to valgus and varus stress throughout the arc of motion, respectively. Moreover, these ligamentous structures contribute to the physiologic rotational stability of the elbow joint. The transition between the upper arm and the forearm is the region of the antecubital fossa, which contains the radial nerve, brachial artery, and median nerve.
In general, elbow trauma can subdivide into the following categories:
Traumatic injuries range from simple contusions to more complex osseoligamentous fracture-dislocation patterns. The latter is often seen following a fall on an outstretched hand while the forearm is supinated and the elbow is either partially flexed or fully extended. Direct trauma to the elbow, which often occurs from a fall directly onto the olecranon can yield various types of fracture- and fracture-dislocation patterns as well. Additionally, isolated soft tissue injuries can range from mild contusions, sprains, and strains to more significant soft tissue-based injuries requiring clinical attention, such as deep penetrating lacerations or gunshot wounds (GSWs) resulting in traumatic arthrotomies. While simple elbow dislocations most often resolve following nonoperative management alone, some patients develop recurrent dislocations or subluxation episodes. These patients present commonly present with painful clicking and weakness.
Another form of elbow injuries consists of the subacute-to-chronic variety that occurs secondary to repetitive motions, eventually leading to various tendinosis conditions. These can include but are not limited to, lateral epicondylitis (tennis elbow), and chronic partial UCL injuries or strains.
Elbow trauma in children most commonly occurs via sport or following falls. Moreover, careful attention during the assessment is necessary, given the characteristic sequence of ossification center appearance and fusion, which can make the radiographic assessment rather challenging. Commonly encountered pediatric elbow fractures include (but are not limited to):
Another common elbow injury in children:
Elbow trauma in the young adult usually occur in the setting of sports and following either an acute avulsion injury, ligamentous injury, or insidiously and progressively with chronic repetitive trauma. Weight lifters often sustain sprains and strains injury to the elbow, accounting for 2.6% of all bodily sprains and strains. Sports that commonly associated with elbow trauma are those with high impact (skateboarding, inline-skating, skiing) and those involved in overarm-throwing sports such as cricket, baseball, and tennis. Overarm-throwing sports usually associated with elbow collateral ligament insufficiency.
The epidemiology of elbow trauma in children is interesting due to a trend toward earlier physical fusion in girls compared to boys. In girls, most physical fractures occur at the ages of 9mto 12 and 12 to 15 years in boys. The boy-to-girl ratio for the incidence of physical fractures when examined for specific ages varied from 1 to 1 in children 11 years old or younger and 7 to 1 in children older than 11 years. About 15% of all pediatric fractures are epicondylar fractures, and the peak incidence of age is around 6 years of age. Elbow dislocation in children is not as common as fracture; it accounts 3 to 5% of all pediatric elbow injuries; mostly the posterolateral type. Peak incidence occurs during adolescence, ages 12 to 13 years.
Patients will present acutely with varying degrees of swelling and deformity. Pain and limited range of motion (ROM) are the expected presentation. A comprehensive physical examination includes examination from the shoulder to the hand of the ipsilateral extremity in question. Case reports in the literature highlight the not uncommon presentation of some combination of the forearm, elbow, and humeral-based fractures. One such report included the presence of an ipsilateral elbow dislocation, humeral shaft fracture, and shoulder dislocation following high energy trauma. The examiner should perform and document relevant findings, including:
How the patient carries their arm may give clues to the diagnosis.
Soft tissue injuries
Sensory and motor testing of the Median and Ulnar nerves:
Acute compartment syndrome can usually develop over a few hours after a serious injury. Some symptoms of acute compartment syndrome are:
Beside acute compartment syndrome, chronic compartment syndrome may develop. Symptoms of chronic compartment syndrome include worsening pain or cramping in the affected muscle within a half-hour of starting an exercise. Symptoms typically go away with rest, and muscle function remains normal.
Clinical features of acute compartment syndrome (ACS)
The initial suspicion of a diagnosis of ACS is mainly clinical. There are some classic features, including pain, pallor, pulselessness, pressure, paraesthesia, poikilothermia, and paralysis. If the patient has all the features, this could indicate a late diagnosis and irreversible damage because some features such as paralysis occur very late in the pathogenesis of ACS. Therefore, it is highly suggested to do a serial assessment to detect a more catastrophic clinical state rather than at one point in time.
Research has taken on the predictive values of the cardinal features. To calculate the predictive value, Bayes used the following features of ACS: pain, paraesthesia, paresis, and pain on passive movement. All features were more specific than they were sensitive: mean specificity is 0.97 (range 0.97 to 0.98) and mean sensitivity 0.16 (range 0.13 to 0.19). The positive predictive values ranged from 0.11 to 0.15, and all negative predictive values were 0.98. The low positive predictive value suggests that these symptoms on their own are poor indicators of ACS.
Once ACS is suspected, definitive diagnosis involves obtaining the intracompartmental pressure. The assessment could be with direct, invasive monitoring. When obtaining intracompartmental pressures, a catheter is placed within 5 cm of the fracture level, with the transducer secured at the level of the measured compartment. It is important to keep the catheter tip outside of the actual fracture site. If placed within the fracture, levels will be falsely high. Failure to place the transducer at the same height of the catheter tip will cause a falsely high or low, depending upon the position. When the first pressure is normal, but ACS is suspected, a compartment recheck is needed, with another pressure assessment.
Although beyond the scope of this review, heightened suspicion is appropriate during the assessment of pediatric patients and infants. Due diligence should be performed to rule out child abuse when applicable.
Radiographic studies that are necessary for all patients presenting with varying degrees of elbow trauma include:
Computerized tomography (CT) scans are often a consideration in the setting of comminuted fracture patterns for pre-operative surgical planning. Magnetic resonance imaging (MRI) can be an option in the setting of soft tissue and ligamentous injury evaluation, or when suspecting stress or occult fractures.
Based on the complex anatomy of the elbow, a few things require attention:
In general, mild soft tissue injuries are manageable with rest, ice, NSAIDs, and early range of motion. The pitfall in managing elbow injuries lies in the fact that the joint gets stiff quickly and depending on patient characteristics, formal physical therapy may be recommended to ensure an overall functional outcome.
The management of elbow trauma and fractures is beyond the scope of this review. However, most fracture patterns with displacement require surgical management with open reduction internal fixation (ORIF) performed, followed by formal physical therapy postoperatively. Simple elbow dislocations (i.e., no associated fracture) almost all can be managed with closed reduction and sling immobilization for 10 to 14 days followed by early ROM. The examiner should take advantage of the initial post-reduction examination, including documented ROM and neurovascular status upon successful reduction of the joint. Performing this examination in the acute setting can help guide not only the duration of joint immobilization in a sling, but the possibility of developing posterolateral rotatory instability (PLRI) that can present chronically with painful clicking, weakness, and feelings of instability with various activity. These patients require operative intervention to mitigate the risk of a poor outcome.
Nondisplaced fractures can be treated with a splint initially, and in general, greater than 2mm of displacement in most fracture patterns require referral for operative consideration.
Emergency department treatment and procedures
Attritional injuries management modalities
Treatment for repetitive trauma such as lateral epicondylitis or tendinitis, demonstrate successful outcomes with nonoperative management modalities alone. These include but are not limited to:
It is crucial to recall that prolong elbow immobilization can cause stiffness to the patient, so the main goal is to get the elbow's range of movement back as soon as possible.
It is important to remember all possible diagnoses including (but not limited to):
Pediatric differential considerations include
The treated fracture usually have a good prognosis. Some patients may demonstrate loss of terminal extension about 10 to 15 degrees, but this is not clinically significant. Dislocation can cause compression of nerve or vascular, and early management of this condition will minimize the complication. Bursitis patients also have a good prognosis. For infectious bursitis, a systemic infection may happen but at very low risk.
The most common complications include neurovascular complications following fracture and dislocation. Transient ulnar neuropathy incidence is 10%. Another less common complication is median nerve entrapment. Vascular complication such as reduction or obliteration of the radial pulse may occur. Prolonged immobilization of elbow can cause stiffness and terminal extension loss, which can be problematic, especially in children and athletes.
Patients are encouraged to follow instructions and post-injury or post-operative rehabilitation protocols as dictating by his or her provider(s). Also, in complex elbow injury patterns and traumatic fracture-dislocations (i.e., terrible triad elbow injuries), it is important to manage patients expectations appropriately. Nearly all patients experience some degree of post-recovery loss of ROM. Thus, it is important to emphasize regaining elbow ROM following any elbow injury.
A thorough evaluation of elbow trauma by the primary care provider, nurse practitioner, and the emergency department physician is vital for optimal patient outcomes. Radiographic evaluation of elbow trauma is an essential tool in the acute setting, and a firm understanding of anatomy, radiographic landmarks, and common injury is necessary. For chronic elbow overuse injury, radiography, and MRI are vital tools for diagnostic. Making the right diagnosis and not delaying treatment can reduce unwanted complication.
Elbow trauma management requires an interprofessional team approach, including physicians, specialists, specialty-trained nurses, physical therapists, and pharmacists, all collaborating across disciplines to achieve optimal patient results. [Level V]
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