Evaluation and Management of Suspected Broken Elbow
Start with standard radiography (AP, lateral, and oblique views) as your initial imaging study for any suspected elbow fracture. 1
Initial Clinical Assessment
Look for these specific clinical findings that suggest fracture:
- Inability to fully extend the elbow (positive elbow extension test) - this has sensitivity up to 98.6% for detecting fractures 2
- Point tenderness over bony prominences (radial head, olecranon, coronoid process) 2
- Visible deformity or swelling 3
- Loss of normal elbow contour 3
A negative elbow extension test (patient can fully extend the elbow) effectively rules out fracture in most cases, though specificity is variable (24-69%) 2
Imaging Algorithm
Step 1: Initial Radiographs
Order standard elbow radiographs (AP, lateral, oblique views) for all patients with acute elbow trauma 1
Step 2: If Radiographs Are Normal or Indeterminate
For suspected occult fracture:
- Order CT without IV contrast as the next study 1
- Alternatively, repeat radiographs in 10-14 days 1
- CT is particularly valuable when the elbow extension test is positive but X-rays appear normal - this identifies occult fractures in approximately 12.8% of cases 4
For suspected soft tissue injury (tendon, ligament, muscle):
- Order either ultrasound or MRI without IV contrast 1
- These are equivalent alternatives for soft tissue evaluation 1
Management Principles
Most elbow fractures require operative treatment with anatomic reduction and rigid internal fixation to restore articular surfaces and prevent long-term stiffness 5
Key Treatment Goals:
- Achieve anatomic reduction of fracture fragments 3, 5
- Restore bony congruity perfectly 5
- Recognize and repair associated ligamentous injuries 5
- Initiate early range of motion to minimize elbow stiffness - the most common complication 3, 6
Simple Dislocations (No Fracture):
- Conservative treatment with early mobilization is first-line therapy 6
- Early functional training produces better ROM than immobilization (extension deficit 16° vs 19.5°) 6
- Consider surgical stabilization only if severe bilateral ligament injuries or moderate-to-severe instability on initial examination 6
Critical Pitfalls to Avoid
- Do not miss occult fractures - if clinical suspicion remains high despite normal radiographs (especially with positive elbow extension test), proceed directly to CT 4
- Do not immobilize for extended periods - prolonged immobilization (>3 weeks) leads to worse extension deficits and ROM 6
- Do not overlook associated ligamentous injuries in fracture-dislocations - these require recognition and repair for optimal outcomes 5
- Do not accept non-anatomic reduction - imperfect articular restoration leads to post-traumatic arthritis and poor function 5