How does a fracture occur?
There are two mechanisms. Direct - a fall or blow directly to the back of the elbow: in this case, the fracture is often comminuted. Indirect - falling on an outstretched arm while simultaneously straining the triceps muscle, which literally tears off the appendix. In any case, the muscle pulls the upper fragment upward, and a gap forms between the fragments. This is why most of these fractures are unstable and cannot be held in the correct position without fixation. In older people, fractures are often comminuted due to the fragility of the bone.
- Direct blow to the back of the elbow
- Fall onto an outstretched arm with triceps tension
- Detachment of the process by traction of the triceps muscle
- Comminuted fractures in the elderly
- Combination with dislocation of the forearm due to severe injury
- Possible ulnar nerve damage
Symptoms
Pain immediately appears in the elbow area, swelling and bruising along the back surface. When the fragments are displaced, a recess is felt under the skin - a gap between the fragments. The main functional sign is loss of active extension: if you raise the shoulder and ask to extend the arm, the forearm hangs. The arm is passively extended, albeit painfully. Be sure to check the sensitivity of the little finger and ring finger, because the ulnar nerve runs next to the bone and can be damaged.
- Pain and swelling in the elbow area
- Recession under the skin when fragments are displaced
- Inability to actively extend the arm
- Bruising on the back of the elbow
- Pain on palpation of the appendix
- Numbness of the little finger due to damage to the ulnar nerve
Diagnostics
X-rays of the elbow joint in direct and, most importantly, lateral projections reveal a fracture and accurately show the amount of displacement. The lateral shot must be strictly followed, otherwise the displacement is easy to underestimate. In case of comminuted fractures, combined with a dislocation of the forearm, or suspected damage to the head of the radial bone, a computed tomography scan is prescribed to plan the operation. Ultrasound and MRI are used less frequently, mainly to evaluate the triceps tendon and ligaments. Be sure to document the condition of the ulnar nerve before treatment.
- X-ray of the elbow joint in two projections
- Strict lateral stacking to assess displacement
- CT scan for comminuted fractures and dislocations
- Ultrasound of the triceps tendon in case of doubt
- Checking hand sensitivity and strength
- Control images after fixation
Treatment
Nondisplaced fractures where active extension is maintained are treated with fixation in a brace or plaster cast in a position of approximately 90 degrees of flexion for 2 to 3 weeks, followed by early development. A control shot after a week is required, because displacement may appear later. In case of displacement, an operation is performed: the classic method is fixation with two knitting needles and a wire tightening loop; for comminuted fractures, special plates are used. In elderly people with low loads, small fragments are sometimes removed and the tendon is sutured. After the operation, movements begin in the first days.
- Flexion brace for 2–3 weeks for non-displaced fractures
- Control photo after a week
- Osteosynthesis with knitting needles and a wire loop
- Plate for comminuted fractures
- Removal of small fragments with tendon refixation in the elderly
- Early development of elbow movements
Rehabilitation and complications
The elbow joint is extremely prone to stiffness, so long-term immobility here is more dangerous than in other joints. Development begins early, increasing the amplitude gradually and without violent jerks. Power loads and support on the arm are allowed only after fusion. A common feature is discomfort from the metal structure under the thin skin of the elbow, which is why the pins and wires are often removed after fusion. Possible complications include limitation of full extension, irritation of the ulnar nerve, and less commonly, nonunion and arthrosis of the joint.
- Early onset of elbow movement
- Gradual increase in amplitude without jerks
- Limitation of arm support before fusion
- Possible removal of the metal structure after fusion
- Monitoring the condition of the ulnar nerve
- Therapeutic exercise under the supervision of a specialist