Authors

Dr Keran Sundaraj MBBS MSc (Trauma) FRACS FAOA

Elbow fractures are common childhood injures. They account for 10% of all childhood fractures. For the majority of injuries, fractures heal well in a cast. However, in more severe injures, surgery may be required. Structures around the elbow, such as nerves, blood vessels and ligaments, surround the elbow. These can be damaged and may require treatment as well.

Anatomy

The elbow is a hinge joint comprised of three bones:

• The humerus - making the upper arm between shoulder and elbow.

• The radius - the thumb side of the forearm.

• The ulna - the little finger of the forearm.

Three major nerves cross the elbow:

• The radial nerve - which supplies the muscles to extend the wrist and fingers

• The median nerve - which supplies the muscles to flex the wrist and some of the fingers and thumb.

• The ulna nerve - which supplies the small muscles in the hand and some of the muscles to flex the ring and little finger.

The main blood vessels to the forearm and hand also cross the elbow. There are several growth plates around the elbow. In children, fractures may be either near or through these growth plates.

Types of Fractures

Supracondylar fractures (above the elbow)

These fractures occur just above the elbow. They usually occur in children under eight years. With more severe injuries, nerves and blood vessels can be impaired. Fractures are classified as;

• Type I - undisplaced. These require casting or a sling for around four weeks.

• Type II - mildly displaced. These may require manipulation under an anaesthetic, which is usually performed in an operating room. Wires may be required to hold the fracture in place. A cast is applied for four to six weeks.

• Type III - significantly displaced. These required a closed (manipulation) or open (an incision) reduction in an operating room under a general anaesthetic. Wires are used to hold the fracture in place. A cast is applied for four to six weeks. The wires are removed when the cast is taken off.

• Type IV - significantly displaced and unstable. On an x-ray, these appear as 'flexion type fracture. Treatment is the same as type III injuries.

Condylar fractures (at the elbow)

These fractures occur through one of the bony knuckles at the end of the humerus. There may be disruption of the physis (growth plate) or the joint surface. Treatment is based on whether the growth plate or the joint surface has shifted.

Epicondylar (around the inner or outer tip of the elbow)

These fractures occur through either the medial (inner) or lateral (outer) tip of the knuckle. These injuries usually occur in children aged 9 to 14 years. For fractures of the medial epicondyle that are significantly displaced, the ulna nerve (the funny bone) can be stretched, causing numbness in the ring and little finger. Occasionally the injury is more significant and results in the elbow dislocating with the epicondyle becoming trapped in the joint. Severe injuries with nerve damage, elbow instability or significant displacement may require surgery with the use of pins or screws. 

Recovery

Splints or casts may be required for 4 to 6 weeks in young children with stable fractures. For older children or those with more unstable fractures, this time is extended to around 6-weeks. Progress x-rays are taken at 1 to 2 weeks to ensure the fracture is still in the correct alignment. If surgery has been performed, x-rays are required close to the time of the cast coming off.

After coming out of a cast, children still need to be careful with the arm. Activities where falling onto the arm is possible is best avoided for 4 to 6 weeks. Impact sports are best to avoid for 3 to 6 months.

What to Discuss with Dr Sundaraj

• How long can I expect off school?

• How long will I be in a cast/splint?

• Do I need to be screened for osteoporosis (weak bones)?

• When can I start physiotherapy?

• When can I return to school?

• When can I return to sport?

• What is the likely outcome from this treatment?

• When do I need to come back?