INJURY TO THE ELBOW
Injuries
of the elbow range from nondisplaced fractures to complex
fracture-dislocations. When a patient presents with an elbow injury, inspect
the elbow and forearm for swelling, ecchymosis, deformity, and wounds such as
abrasions or lacerations that could raise concern for an open injury. Palpate
the area of maximal tenderness, and assess the joint above (shoulder) and below
(wrist) for additional areas of tenderness that could suggest other injuries.
Palpation can also be utilized to detect for the presence of a joint effusion
associated with the injury. An effusion is, again, most easily noted by palpation
over the posterolateral “soft spot” of the elbow. Elbow range of motion may be
limited after an acute injury owing to pain or because of the presence of a
fracture or dislocation. A thorough distal neurovascular examination is
mandatory to determine if damage has occurred to any neurovascular structures
from the injury. After an elbow fracture, the elbow show be supported and
immobilized with a well-padded posterior elbow splint incorporating both the
upper arm and forearm. The entire injured limb can then be placed in a sling
for added comfort.
Plain radiographs should initially be
obtained to determine the fracture pattern and/or dislocation type after a
significant elbow injury. Nondisplaced fractures may not be easy to detect on
plain radiographs, but a fat pad sign may be present. In an uninjured elbow,
the anterior fat pad of the distal humerus may be seen on a lateral radiograph
whereas the posterior fat pad is typically absent. A fracture near the
elbow, such as a radial head or neck fracture or a supracondylar fracture,
causes an elbow effusion that elevates both the anterior and posterior fat
pads, making both evident on a lateral radiograph. Displaced fractures may be
easily seen on plain radiographs, but computed tomography (CT) or magnetic resonance
imaging (MRI) is often needed to better delineate the fracture pattern,
particularly when the fracture extends into the elbow joint or when multiple
fracture fragments are present. MRI may also be useful to determine if a
collateral ligament injury has occurred. After an elbow dislocation, it is
essential to obtain plain radiographs after the joint has been successfully
reduced to confirm that the elbow is properly aligned. Multiple views should be
taken, because the presence of a persistent dislocation or subluxation of the
joint may be missed with only one radiographic view.
