What is the appropriate initial assessment and management for a patient presenting with a left elbow injury?

Initial Assessment and Management of Left Elbow Injury

Begin with plain radiographs of the elbow in all patients presenting with acute elbow injury to exclude fractures, dislocations, heterotopic ossification, and joint effusions. 1, 2

Initial Clinical Assessment

Key history elements to obtain:

• Mechanism of injury (fall on outstretched hand, direct blow, throwing motion, twisting injury) 3, 4
• Timing and onset of pain (acute traumatic vs. gradual onset) 4
• Location of pain (anterior, medial, lateral, or posterior elbow) 4
• Presence of clicking, snapping, clunking, or locking sensations suggesting instability 5, 6
• Occupational and athletic activities, particularly overhead throwing or repetitive motions 7, 4

Critical physical examination findings:

• Point tenderness over specific anatomic structures (epicondyles, olecranon, radial head) 4
• Ability to fully extend the elbow (inability suggests occult fracture) 1
• Posterolateral rotatory apprehension test for instability (most sensitive test) 5, 6
• Neurovascular status, particularly ulnar nerve function 4
• Joint effusion or swelling suggesting intra-articular pathology 1, 2

Imaging Algorithm

Step 1: Plain Radiographs (Always First)

• Obtain standard anteroposterior and lateral views of the elbow 1, 2
• Radiographs identify fractures, dislocations, avulsion injuries, heterotopic ossification, and joint effusions 2, 8
• Look specifically for posterior fat pad sign indicating occult fracture 1

Step 2: If Radiographs Normal but Fracture Still Suspected

• Either repeat radiographs in 10-14 days OR obtain CT without IV contrast (these are equivalent alternatives per the American College of Radiology) 1
• CT is superior for characterizing fracture morphology, identifying occult radial head, olecranon, and coronoid fractures 1
• CT demonstrates 12.8% occult fracture detection rate when radiographs are equivocal 1

Step 3: If Radiographs Normal but Soft Tissue Injury Suspected

• Either ultrasound OR MRI without IV contrast (these are equivalent alternatives per the American College of Radiology) 1
• MRI demonstrates 87.5% concordance for medial collateral ligament injuries and 90.9% for lateral collateral ligament injuries compared to surgical findings 1
• MRI is particularly useful for biceps/triceps tendon tears, ligamentous injuries after dislocation, and UCL injuries in overhead athletes 1
• Ultrasound shows 96% sensitivity and 81% specificity for UCL tears with dynamic stress testing 1

Important caveat: Do not proceed to advanced imaging (MRI, CT) without completing at least 4-6 weeks of conservative treatment unless there are red flags suggesting fracture, dislocation, or neurovascular compromise 2

Initial Management

Conservative treatment (successful in approximately 80% of cases within 3-6 months):

• Rest and activity modification while avoiding complete immobilization to prevent muscle atrophy 2
• Ice application for 10-minute periods through a wet towel 2
• Topical NSAIDs preferred over oral NSAIDs in elderly patients to avoid gastrointestinal, renal, and cardiovascular risks 2
• Physical therapy with eccentric strengthening exercises and wrist extensor stretching 2

Red flags requiring urgent evaluation:

• Inability to extend elbow (suggests occult fracture requiring CT) 1
• Neurovascular compromise 4
• Fever, spreading erythema, or systemic symptoms (suggests infection) 8
• Obvious deformity or dislocation (requires immediate orthopedic consultation) 3
• Rapidly enlarging soft tissue mass (consider sarcoma or compartment syndrome) 8

Common Pitfalls to Avoid

• Do not skip initial radiographs even when soft tissue injury seems obvious, as associated fractures are common 1, 3
• Do not order MRI as initial study for acute elbow strain; reserve for persistent symptoms after 4-6 weeks of conservative management 2
• Do not use CT, bone scan, or contrast-enhanced imaging for initial soft tissue injury evaluation 1
• Do not overlook associated injuries in elbow dislocations: coronoid fractures, radial head fractures, and collateral ligament tears commonly occur together 1, 3
• Do not use corticosteroid injections as first-line treatment in elderly patients, as they provide only short-term relief and may inhibit healing 2

When to Consider Surgical Referral

• Pain persisting despite 6-12 months of well-managed conservative treatment 2
• Recurrent instability with positive posterolateral rotatory apprehension test 5, 6
• Complete tendon ruptures (biceps, triceps) 1
• Displaced fractures or fracture-dislocations 3
• Heterotopic ossification causing mechanical symptoms refractory to conservative management 2