What is the appropriate management for a patient with elbow swelling and tenderness after trauma?

Management of Elbow Swelling and Tenderness After Trauma

Obtain plain radiographs immediately as the first-line imaging to identify fractures, dislocations, and other bony pathology that require urgent intervention. 1

Initial Clinical Assessment

Perform a focused examination looking for:

• Neurovascular status - Assess pulses, capillary refill, and nerve function, as anterior dislocations and severe trauma can cause brachial artery injury and nerve palsies 2
• Joint stability - Test for gross instability suggesting dislocation requiring immediate reduction 1
• Deformity and range of motion - Document baseline function and identify obvious dislocations 3
• Swelling pattern - Diffuse swelling suggests intra-articular pathology or significant soft tissue injury 4

Imaging Algorithm

Step 1: Plain Radiographs (Always First)

• Obtain standard elbow radiographs (AP, lateral, and oblique views) to rule out fractures, dislocations, intra-articular bodies, and occult fractures 1, 5
• Compare with contralateral elbow if asymmetry is suspected 1
• This is the most appropriate initial imaging modality for acute trauma 1

Step 2: Advanced Imaging (If Radiographs Are Negative or Equivocal)

• Consider CT if complex fracture patterns are suspected or for surgical planning 4
• MRI is indicated when soft tissue injuries (ligaments, tendons, cartilage) are suspected despite negative radiographs, particularly if symptoms persist 1, 6
• Dynamic ultrasound can detect nerve dislocation and snapping pathology with 96% sensitivity if clinical suspicion remains high 7

Treatment Based on Findings

If Fracture or Dislocation Identified:

• Immediate closed reduction for dislocations to minimize morbidity and restore anatomic alignment 2, 3
• Surgical consultation for unstable fractures, open injuries, or neurovascular compromise 3, 4
• Post-reduction stability testing under fluoroscopy helps guide treatment: gross instability (frank redislocation) requires surgical fixation, while mild instability (<10° widening) can be managed conservatively with better functional outcomes (MEPS 77.6% vs 52.6%) 1

If No Fracture/Dislocation (Soft Tissue Injury):

• Rest and activity modification - Avoid provocative movements 5, 7
• NSAIDs for acute pain relief 1, 5, 7
• Ice application to reduce swelling 1
• Early range-of-motion exercises once acute pain subsides to prevent elbow stiffness, which is a major source of morbidity 3
• Physical therapy with eccentric strengthening exercises if tendinopathy is suspected 1, 5

Second-Line Interventions (If Conservative Management Fails After 3-6 Months):

• Corticosteroid injections may provide pain relief but should be used cautiously and not as a substitute for addressing biomechanical issues 1, 5
• Most overuse tendinopathies recover within 3-6 months with conservative treatment (80% success rate) 1

Critical Pitfalls to Avoid

• Missing neurovascular injury - Always assess vascular status and nerve function, as anterior dislocations frequently cause brachial artery and nerve injuries requiring immediate intervention 2
• Delaying reduction - Dislocations should be reduced promptly to minimize complications including stiffness and neurovascular compromise 2, 3
• Static imaging missing dynamic pathology - If symptoms persist despite negative MRI, consider dynamic ultrasound or stress fluoroscopy 1, 7
• Inadequate immobilization or excessive immobilization - Balance protection with early mobilization to prevent elbow stiffness, the most common complication 3, 4
• Overlooking subtle fractures - Coronoid process and radial head fractures can be missed on initial radiographs but significantly impact stability 4