What is the treatment for an elbow fracture?

Treatment of Elbow Fractures

The treatment of elbow fractures prioritizes achieving stable, anatomic reduction through operative fixation for most displaced fractures, with early mobilization to prevent joint stiffness and maximize functional outcomes. 1

Initial Diagnostic Approach

First-Line Imaging

• Radiographs are the mandatory initial imaging study for all suspected elbow fractures to assess displacement, comminution, and joint involvement 2
• Look for joint effusion indicated by posterior and anterior fat pad elevation on radiographs, which may suggest an occult fracture even when no obvious fracture line is visible 2
• Comparison views with the contralateral elbow can help identify subtle asymmetry 3

Advanced Imaging When Radiographs Are Indeterminate

• CT without contrast is indicated when radiographs are normal or indeterminate but clinical suspicion remains high, as it identifies occult fractures and clarifies fracture morphology critical for surgical planning 3, 2
• CT is particularly valuable for identifying occult radial head, olecranon, and coronoid process fractures, with studies showing 12.8% of patients with negative radiographs but positive elbow extension tests had fractures on CT 3
• MRI without contrast is reserved for suspected soft tissue injuries (ligaments, tendons, muscles) when radiographs are normal 3

Treatment Algorithm

Operative vs. Non-Operative Decision-Making

Most elbow fractures require operative treatment to restore articular surfaces and achieve rigid internal fixation 4. The decision is based on:

• Fracture displacement: Displaced fractures require anatomic reduction 1
• Joint stability: Assess for associated ligamentous injuries and instability patterns 5
• Fracture pattern complexity: Simple vs. complex fracture-dislocations 5
• Associated injuries: Coronoid, radial head, or ligamentous disruption significantly affects stability 6

Specific Fracture Patterns

Posterolateral fracture-dislocations (most common):

• Characterized by radial head fracture ± anterolateral coronoid fracture with lateral collateral ligament injury 5
• "Terrible triad" injuries (radial head + coronoid anterolateral facet fractures + dislocation) require aggressive surgical stabilization 5
• Operative fixation of all bony and ligamentous components is essential 5

Posteromedial fracture-dislocations:

• Involve anteromedial coronoid facet fracture with lateral collateral ligament avulsion 5
• These are varus posteromedial rotatory injuries requiring recognition of the specific injury pattern for appropriate surgical approach 6

Olecranon fracture-dislocations:

• Complex injuries with disruption of the greater sigmoid notch requiring skeletal distraction to facilitate reduction 6
• Radioulnar relationship preservation guides treatment approach 6

Monteggia fracture-dislocations:

• Proximal ulnar fracture with radial head dislocation 5
• Apex posterior variants have worse prognosis and commonly require radial head fixation and lateral ligament repair 5

Critical Treatment Principles

The primary goal is anatomic reduction with rigid internal fixation allowing early range of motion 1, 7:

• Prolonged immobilization leads to devastating elbow stiffness and limited mobility 7
• Articular surfaces must be restored perfectly 4
• Associated soft tissue injuries (collateral ligaments) must be recognized and repaired or reconstructed 4

Common Pitfalls to Avoid

• Underestimating radial head fracture severity: Articular injury is commonly more severe than plain radiographs suggest, with fragments often located anteriorly 6
• Missing coronoid fractures: The coronoid is critical for stability; when fractured, the radial head becomes essential and must be preserved or replaced 6
• Inadequate assessment of stability: Use fluoroscopic stress testing to evaluate ligamentous integrity—joint widening >10° indicates moderate instability requiring surgical intervention 3
• Implant placement errors: Radial head implants must be placed in the "safe zone" to avoid impingement 6

Post-Reduction Management

After closed reduction of simple dislocations, fluoroscopic stress testing should assess stability 3:

• <10° widening = slight instability → conservative treatment

• 10° widening = moderate instability → consider surgical fixation

• Frank redislocation = gross instability → surgical fixation mandatory 3