Elbow fracture

In young healthy bone, distal humerus fractures require a high impact mechanism to break. However, osteoporotic, or weaker bone can break at the distal humerus with lower energy mechanisms such as ground level falls. Unless there is minimal displacement, distal humerus fractures generally require operative intervention. Surgeons will generally place two plates with screws to minimize rotation in the healing process. Complications include ulnar neuritis, and heterotrophic ossification or other elbow stiffness.

Radial head fractures occur as a result of a valgus force, or from the outside towards the body’s midline. As such, they occur in isolation, or in combination with other injuries to other structures in a fracture-dislocation. They are characterized by the Mason classification listed below:

• Type I: displaced <2mm, forearm rotation intact.
• Type II: displaced >2mm or angulated.
• Type III: comminuted and displacement that causes reduced forearm rotation.
• Type IV: fracture and associated dislocated elbow.{{Cite web |last1=Sanchez-Sotelo |first1=Joaquin |last2=Abboud |first2=Joseph |last3=Myers |first3=Devon |date=February 24, 2025 |title=Radial Head Fractures - Trauma - Orthobullets |url=https://www.orthobullets.com/trauma/1019/radial-head-fractures |access-date=2025-02-25 |website=www.orthobullets.com}}

Only Mason type I fractures are treated non-operatively. If there is displacement, or limit to forearm rotation, a surgeon may choose to either perform and open reduction with plate and screw fixation or replacement of the radial head.

The most common mechanisms of injury in olecranon fractures is fall on and outstretched hand and trauma directly to the bony process. Olecranon fractures have been described by a variety of classification systems including Mayo, Colton, and Schatzker,{{Cite web |last1=Karadsheh |first1=Mark |last2=Sanchez-Sotelo |first2=Joaquin |date=February 14, 2024 |title=Olecranon Fractures - Trauma - Orthobullets |url=https://www.orthobullets.com/trauma/1022/olecranon-fractures |access-date=2025-02-25 |website=www.orthobullets.com}} but the consensus among orthopedic surgeons is operative management is indicated if there is greater than 2 cm displacement. Conservative management can additionally be considered if the patient is elderly and has minimal demand and weight-bearing of the elbow joint. Operative management includes ORIF with tension band wiring (TBW) or plate and screw fixation. Olecranon fracture lines have a compression side, or side where the ends of bone are compressed when the attached muscles contract and a tension side where the ends of the bone pull apart on contraction of the muscles. TBW allows the tension side of fractures to be converted to compression which encourages bone healing.{{Cite journal |last1=Tosti |first1=Rick |last2=Hozack |first2=Bryan A. |last3=Mudgal |first3=Chaitanya S. |date=2020-12-15 |title=Tension Band Wiring in Upper Extremity Surgery |url=https://pubmed.ncbi.nlm.nih.gov/32991386/ |journal=The Journal of the American Academy of Orthopaedic Surgeons |volume=28 |issue=24 |pages=1009–1016 |doi=10.5435/JAAOS-D-19-00449 |issn=1940-5480 |pmid=32991386}} Tension bands are associated with lower cost, shorter operative times and less bleeding, but have higher complications due to a follow-up operation required to remove the hardware compared to plate and screw fixation. Regardless, there is no difference in long term range of motion between TBW and plating.{{Cite journal |last1=Jia |first1=Yizhen |last2=Liu |first2=Aifeng |last3=Guo |first3=Tianci |last4=Chen |first4=Jixin |last5=Yu |first5=Weijie |last6=Zhai |first6=Jingbo |date=2022-08-03 |title=Efficacy and safety of tension band wire versus plate for Mayo II olecranon fractures: a systematic review and meta-analysis |journal=Journal of Orthopaedic Surgery and Research |volume=17 |issue=1 |pages=373 |doi=10.1186/s13018-022-03262-7 |doi-access=free |issn=1749-799X |pmc=9351198 |pmid=35922818}}  Other postoperative complications include arthritis especially in comminuted fractures where the joint surface is disrupted, and stiffness which is more commonly seen in non-operative patients.

Isolated fractures of the coronoid process of the elbow are caused by hyperextension of posterior (behind the elbow) forces. These posterior forces are either varus posteromedial or valgus posterolateral. The Mayo classification describes the location of the fracture line on the coronoid process:

• Type I: tip of the coronoid process
• Type II: 50% of the process
• Type III: >50% of the process

From type I to type III fractures were associated with higher rates of elbow dislocation and lower rates of satisfaction in return to function.{{Cite journal |last1=Regan |first1=William |last2=Morrey |first2=Bernard |date=1989 |title=Fractures of the coronoid process of the ulna |url=https://pubmed.ncbi.nlm.nih.gov/2793888/ |journal=The Journal of Bone and Joint Surgery. American Volume |volume=71 |issue=9 |pages=1348–1354 |doi=10.2106/00004623-198971090-00011 |issn=0021-9355 |pmid=2793888}}

The terrible triad of the elbow (not to be confused with the terrible triad of the knee) is a combination of:

• A fracture of the head of radius
• A fracture of the coronoid process of the ulna
• Humeroulnar dislocation (generally posterior or posterolateral){{cite journal |vauthors=Seijas R, Ares-Rodriguez O, Orellana A, Albareda D, Collado D, Llusa M |year=2009 |title=Terrible triad of the elbow. |url=http://www.josonline.org/pdf/v17i3p335.pdf |journal=J Orthop Surg (Hong Kong) |volume=17 |issue=3 |pages=335–9 |doi=10.1177/230949900901700319 |doi-access=free|pmid=20065376 }}

Treatment for the terrible triad involves treating all three components injured: the coronoid process and radial head with techniques previously described, and the ulnar collateral ligament which is usually injured in posterior elbow dislocation. Due to the severity and complexity of the of terrible triad injury, postoperative complications are very high and include osteoarthritis, persistent instability, and stiffness.{{Cite journal |last1=Ohl |first1=Xavier |last2=Siboni |first2=Renaud |date=2021 |title=Surgical treatment of terrible triad of the elbow |url=https://pubmed.ncbi.nlm.nih.gov/33333276/ |journal=Orthopaedics & Traumatology, Surgery & Research |volume=107 |issue=1S |pages=102784 |doi=10.1016/j.otsr.2020.102784 |issn=1877-0568 |pmid=33333276}}

Due to the shape of the humerus bone – the most thin and weakest point are above the condyles, and children’s tendency to break their falls with on outstretched arm locked in extension, supracondylar humerus fractures are the most common elbow fracture in children.{{Citation |last1=Hope |first1=Natalie |title=Supracondylar Humerus Fractures |date=2025 |work=StatPearls |url=https://www.ncbi.nlm.nih.gov/books/NBK560933/ |access-date=2025-03-06 |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=32809768 |last2=Varacallo |first2=Matthew A.}} Lateral condyle and medial epicondyle fractures (also known as “little league elbow”) make up the next most common pediatric fractures.{{Citation |last1=Saeed |first1=Wajeeha |title=Elbow Fractures Overview |date=2025 |work=StatPearls |url=https://www.ncbi.nlm.nih.gov/books/NBK441976/ |access-date=2025-03-06 |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=28723005 |last2=Waseem |first2=Muhammad}}

Supracondylar humerus fractures can be further divided into extension types and flexion types, which indicates the mechanism of injury. The extension type presents as the elbow being displaced posterior, or behind to the humerus and makes up approximately 95% of supracondylar humerus fractures. Complications of the extension type include anterior interosseus nerve and brachial artery injury. The flexion type, making up the other 5%, results in the elbow being displaced anterior to, or in front of, the humerus. Ulnar nerve palsies are seen in the flexion type injury. The degree of displacement of extension type supracondylar humerus fractures is characterized using the Gartland classification below:

• Type I: minimally or non-displaced fracture with both cortices of the humerus intact.
• Type II: anterior cortex is disrupted, but the posterior remains intact. Subtype IIA denotes a type II fracture with not rational instability, type IIB indicates rotational instability.
• Type III: complete displacement with both cortices disrupted.

Type I fractures are treated with a mid-shaft humeral cast and sling. Type IIB and III fractures require surgery with percutaneous pinning. Type IIA fractures are treated on a case-by-case basis depending mostly on the treating physician’s judgement of a cast’s ability to hold the fracture in place.

Lateral condyle fractures occur when the outside eminence on the elbow end of the humeral bone chips off. They are the second most common type of pediatric elbow fractures and are characterized by the Milch classification. Lateral condyle fractures are treated surgically with and open reduction and Kirschner wires if the fracture fragment is displaced by 2 mm or the surface of the joint is affected by the fracture line. If neither of these characteristics are present, they can be treated without surgery with an above-elbow cast.{{Citation |last1=Martins |first1=Tiago |title=Pediatric Lateral Humeral Condyle Fractures |date=2025 |work=StatPearls |url=https://www.ncbi.nlm.nih.gov/books/NBK560664/ |access-date=2025-03-06 |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=32809499 |last2=Tiwari |first2=Vivek |last3=Marappa-Ganeshan |first3=Raghavendra}}

Medial epicondyle fractures are the third most common type of pediatric elbow fracture. They are a disruption of the medial epicondyle growth plate and occur from repeated valgus stress on the elbow in activities such as throwing a baseball. They are treated with rest from the offending sport or activity.{{Citation |last1=Hodge |first1=Christopher |title=Medial Epicondyle Apophysitis (Little League Elbow) |date=2025 |work=StatPearls |url=https://www.ncbi.nlm.nih.gov/books/NBK570592/ |access-date=2025-03-06 |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=34033354 |last2=Schroeder |first2=Jeremy D.}}

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Category:Bone fractures

Category:Medical triads