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.