Elbow Fractures

Acute elbow fracture presents with pain, swelling, and reduced range of motion after a fall or direct injury. Localised tenderness, deformity (particularly in displaced distal humeral fractures), inability to fully extend (a sensitive screen for occult fracture), and inability to actively extend against gravity (suggests olecranon fracture or extensor disruption) are the major signs.

Neurovascular examination is mandatory and must be documented: radial pulse, capillary refill, median nerve including the anterior interosseous nerve (OK sign), ulnar nerve (intrinsic strength, finger crossing, sensation over volar little finger), and radial nerve (extension at MCP, sensation in dorsal first webspace). Specifically test posterior interosseous nerve function in radial head and neck injuries.

Classic associations:

• •Forearm pain with rotation after a fall on the outstretched hand suggests radial head fracture
• •Tender DRUJ plus radial head fracture suggests Essex-Lopresti
• •Tender forearm with proximal ulna deformity and a dislocated radial head is Monteggia
• •Numbness or weakness in the hand with a displaced supracondylar fracture is a neurovascular emergency

In children, consider safeguarding and non-accidental injury where the mechanism is inconsistent, presentation is delayed, injuries are multiple, the fracture pattern is unusual, or other concerns arise (NICE NG38).

Plain radiographs are first-line: AP and true lateral elbow views.

Key radiographic checks:

• •Anterior humeral line: should bisect the middle third of the capitellum on the lateral. Loss suggests supracondylar fracture in children
• •Radiocapitellar line: should pass through the centre of the capitellum on every view. Disruption suggests radial head dislocation, including Monteggia
• •Fat pad sign: posterior fat pad is always pathological; large anterior sail sign indicates intra-articular effusion and an occult fracture. In adults this most often represents a radial head fracture; in children, a supracondylar fracture

After radial head fractures, always examine the wrist, forearm, and DRUJ. Have a low threshold for wrist and forearm radiographs, especially with wrist or forearm pain, high-energy mechanism, Mason II or III injury, DRUJ tenderness, or suspected longitudinal instability (Essex-Lopresti). Image the entire forearm in suspected ulna fractures to exclude Monteggia. Oblique views may help with radial head and coronoid assessment.

CT is indicated for surgical planning of complex distal humerus fractures, comminuted radial head fractures, and coronoid fractures, particularly to assess fragment morphology and articular involvement. MRI is rarely needed acutely; it is reserved for occult fractures with persistent symptoms or chronic ligamentous instability assessment. Ultrasound has a niche role only.

Most elbow fractures are referred to fracture clinic from the ED or minor injuries unit. The general principle is that non-displaced or stable fractures are managed in a sling or removable splint with EARLY mobilisation, and displaced or unstable fractures, intra-articular fractures, and fractures with neurovascular compromise are operative. Open fractures should NOT be irrigated or closed in primary care: cover appropriately, do not delay, and refer urgently for the open-fracture pathway (early IV antibiotics in ED, theatre per BOAST and NICE NG37).

Elbow stiffness is the dominant complication. Avoid prolonged immobilisation. Mobilise within 7-10 days for stable fractures. Sling is for comfort, not as a treatment.

Radial head fractures:

• •Mason I (non-displaced): broad-arm sling for comfort with early mobilisation within 7-10 days
• •Mason II (displaced): may be managed non-operatively if stable and there is no mechanical block. Operative fixation considered for mechanical block to rotation, clinically important displacement, instability, large articular involvement, or associated injuries
• •Mason III (comminuted): management depends on reconstructability and stability. Options include fixation, radial head arthroplasty, or rarely excision in selected low-demand isolated injuries. Avoid excision where Essex-Lopresti, interosseous membrane injury, or ligamentous instability is present
• •Mason IV: urgent reduction and stabilisation

Olecranon fractures:

• •Mayo I (non-displaced): sling and early mobilisation
• •Mayo II and III: usually require operative fixation in active patients (tension-band wiring for transverse, plate fixation for oblique or comminuted patterns). Selected frail, elderly, low-demand patients may be managed non-operatively after specialist discussion

Coronoid fractures: small tip fractures (Regan-Morrey I) often need no specific treatment; larger fragments (II, III) require fixation, especially in terrible triad reconstruction.

Distal humeral fractures: displaced intra-articular fractures usually need operative fixation (dual-plate ORIF) in younger or higher-demand patients. Total elbow arthroplasty is reserved for carefully selected elderly, low-demand patients with unreconstructable comminution or poor bone stock, with counselling about surgeon-specific lifelong lifting restrictions.

Paediatric supracondylar humeral fractures (BOAST-aligned): document radial pulse, capillary refill, radial nerve, median nerve (including AIN), and ulnar nerve function; surgery is usually on the day of injury; URGENT surgery is required for absent radial pulse, impaired hand perfusion, open injury, or threatened skin; if the limb remains ischaemic after reduction, brachial artery exploration is required. Gartland I: long-arm cast at 90 degrees flexion for 3-4 weeks. Gartland II: selectively operative based on rotation and angulation. Gartland III and IV: usually closed reduction and percutaneous K-wiring, urgency determined by vascular status, open injury, threatened skin, neurological compromise, and local paediatric orthopaedic pathway.

Terrible triad injuries require urgent specialist orthopaedic assessment because they are highly unstable; most require operative stabilisation, but treatment depends on post-reduction stability, fragment size, radial head reconstructability, and ligament injury pattern. Monteggia and Essex-Lopresti are operative emergencies in adults; missing them leads to long-term forearm dysfunction and chronic instability.

Rehabilitation principles centre on early protected motion to combat stiffness, the dominant complication of all elbow injuries. For non-displaced or stable fractures (Mason I, Mayo I, undisplaced patterns), early mobilisation within 7-10 days with simple analgesia and passive then active range exercises is the rule. Sling use is for comfort only and should be removed for exercises from day one to two.

After ORIF or radial head replacement, rehabilitation is surgeon-specific:

• •Phase 1 (weeks 0-6): protected range of motion, often hinged brace with progressive flexion-extension arc
• •Phase 2 (weeks 6-12): progressive strengthening, isometric then isotonic, focusing on biceps, triceps, and forearm rotators
• •Phase 3 (3-6 months): sport-specific loading

Return to throwing or contact sports is typically 4-6 months post-injury, gated by symmetric range and strength.

Persistent stiffness beyond 12-16 weeks despite optimised rehabilitation may warrant referral for arthrolysis, dynamic splinting, or specialist hand therapy. Heterotopic ossification is an under-recognised cause of stiffness, particularly after distal humeral fractures and in head-injury combinations.

Forced passive stretching is CONTRAINDICATED in elbow rehabilitation - it exacerbates stiffness and increases the risk of heterotopic ossification. Rely on active and active-assisted range of movement.

• •NICE NG38 Fractures (non-complex) - The UK framework for non-complex fracture assessment and management; includes analgesia ladder and safeguarding considerations for paediatric injuries.
• •NICE NG37 Fractures (complex) - Covers complex fracture pathways including open injuries and major trauma; works alongside BOAST.
• •BOAST Management of Open Fractures - The UK trauma standard for open elbow injury: IV antibiotics ideally within 1 hour, tetanus management, limited wound handling, photographic documentation, urgent senior orthopaedic input.
• •BOAST Supracondylar Fractures of the Humerus in Children - Defines the paediatric pathway: full neurovascular documentation, same-day surgery for most displaced injuries, urgent operation for vascular compromise or threatened skin.
• •Mason and Mayo classifications - Drive operative-vs-non-operative decisions for radial head and olecranon fractures respectively. Combined with the Regan-Morrey coronoid classification, these are the high-yield frameworks tested in elbow trauma SBAs.

• •DipMSK favourites: radial head fracture (Mason classification, fat pad sign, exclude Essex-Lopresti); paediatric supracondylar fracture (Gartland classification, anterior humeral line, neurovascular emergency in Gartland III/IV); and the named associations Monteggia and Essex-Lopresti.
• •MUGR mnemonic (mugger): Monteggia = Ulna fracture (with radial head dislocation); Galeazzi = Radius fracture (with distal radioulnar joint dislocation).
• •Elbow stiffness is the dominant complication. Early mobilisation within 7-10 days is the rule for stable fractures. Forced passive stretching is CONTRAINDICATED.
• •Radiocapitellar line passes through the centre of the capitellum on every view, disrupted in Monteggia. Anterior humeral line bisects the middle third of the capitellum on the lateral, lost in supracondylar. Posterior fat pad sign is always pathological.
• •CRITOE for paediatric ossification centres: Capitellum 1, Radial head 3, Internal medial epicondyle 5, Trochlea 7, Olecranon 9, External lateral epicondyle 11. Trapped medial epicondyle trick: if Trochlea is present but the medial epicondyle is not, suspect avulsion entrapped in the joint.
• •Hyperpronation is the preferred first-line reduction manoeuvre for pulled elbow (radial head subluxation in toddlers); higher first-time success and less pain than supination-flexion. Differentials for acute elbow pain in trauma: acute elbow dislocation, pulled elbow, septic arthritis, gout or pseudogout, and lateral or medial epicondylopathy.