What is the appropriate management for an elbow fracture?

Management of Elbow Fractures

The appropriate management of elbow fractures requires initial radiographic evaluation with standard views, followed by either conservative or surgical treatment based on fracture characteristics including displacement, stability, and joint involvement. 1

Diagnostic Imaging

• Initial Evaluation: Standard radiographs including posteroanterior, lateral, and oblique views are essential for proper evaluation of elbow fractures 1
• Advanced Imaging:
  • CT elbow is recommended for complex fracture patterns, identifying the origin of dislocated fragments, and positions of displaced fragments 1
  • MRI elbow is valuable when soft tissue injuries are suspected alongside fractures 1
  • CT arthrography or MR arthrography may be needed for detailed assessment of osteochondral lesions 1

Treatment Algorithm

Conservative Management

Conservative treatment is appropriate for:

• Fractures with minimal displacement (<10 degrees angulation)
• Stable fractures
• Fractures with less than 50% joint involvement 2

Conservative treatment typically involves:

1. Immobilization with a splint or cast for 2-3 weeks
2. Early finger motion exercises to prevent stiffness and edema
3. Progressive range of motion exercises after immobilization period
4. NSAIDs for pain and inflammation control 2

Surgical Management

Surgical intervention is indicated for:

• Unstable fractures
• Displaced fractures (especially in patients under 65 years)
• Fractures with significant joint involvement (>50%)
• Fracture-dislocations 2, 3

Surgical options include:

1. Open reduction and internal fixation (ORIF) with plates and screws
2. Tension band wiring for olecranon fractures
3. Fragment-specific fixation for complex fractures
4. Radial head replacement when reconstruction is not feasible 3, 4

Special Considerations for Fracture-Dislocations

Elbow fracture-dislocations represent particularly complex injuries with three main patterns 5:

1. Valgus posterolateral rotatory instability

   • Requires repair of lateral collateral ligament complex
   • May need radial head fixation or replacement

2. Varus posteromedial rotatory instability

   • Often involves anteromedial coronoid fractures
   • Requires fixation of coronoid and attention to medial collateral ligament

3. Transolecranon fracture-dislocation

   • Requires anatomic reduction and stable fixation of olecranon
   • Assessment of associated injuries to coronoid and radial head 5, 3

Rehabilitation Protocol

• Begin early finger motion immediately after surgery or immobilization to prevent stiffness
• Progress to active-assisted elbow motion once stable
• Strengthen muscles around the elbow when fracture shows signs of healing
• Consider a directed home exercise program which can be as effective as supervised therapy for uncomplicated fractures 2

Complications and Prevention

• Monitor for joint stiffness, chronic pain, post-traumatic arthritis
• Ensure compliance with rehabilitation protocols
• Regular assessment of wound healing and radiographic union
• Consider secondary fracture prevention strategies in elderly patients 2

Pitfalls to Avoid

• Inadequate imaging leading to missed associated injuries
• Prolonged immobilization causing stiffness
• Failure to recognize and address instability patterns in fracture-dislocations
• Underestimating the severity of articular injury to the radial head, which is often more severe than noted on plain radiographs 6
• Delayed treatment of complex elbow fractures, which can lead to poor functional outcomes 4

By following this structured approach to elbow fracture management, clinicians can optimize outcomes and minimize complications for patients with these challenging injuries.