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Injuries around the Elbow and Forearm

The elbow comprises three joints: the main hinge is between the trochlea of your humerus and the socket of your ulna.  Rotation of your forearm is achieved at the junction between capitellum and radial head (see diagram). The third joint between your upper ulna and upper radius also allows rotation.  The depth of your socket, the elbow ligaments, muscles that cross the elbow and the capsule all contribute to stability.  The elbow can be injured by direct force (e.g. landing on tip of your elbow) or by indirect force (e.g. landing on your hand)

Your forearm comprises two bones, your radius and your ulna.  The Radius is the dominant bone at your wrist, but the ulna forms the hinge at your elbow. Fibrous tissue called the interosseous membrane connects the two bones.  Both bones work as a unit, which means that normally both break and, if only one breaks, the other bone can dislocate. 

Figure 1 View from the front of your elbow

Figure 2 View from the back of your elbow

Radial Head and Neck Fractures

These typically follow a fall onto an outstretched hand as the force is transmitted up the forearm to your elbow.  Most do not require surgery and you will be encouraged to mobilise your elbow after only a short period of immobilisation (1 week).  Minor stiffness is common after this injury, so early motion is important.  Significantly displaced fractures and those that block your forearm rotation may require surgery.  Fractures can be fixed by screws alone, or with plates and screws. Your fracture is fixed through an incision over the outer aspect of your elbow. 

Occasionally the radial head is too badly damaged to be reconstructable,. In this case a radial head replacement may be required.  Sometimes a fractured radial head is removed, although this is normally avoided in the acute period.

Risks of surgery include: stiffness, new bone formation, nerve injury (uncommon and, if it occurs, it is normally temporary), arthritis and failure of the bone to heal.

You do not normally go into a cast for more than a fortnight after radial head fixation to avoid stiffness.

Intra-operative views of radial head screws (note also the plates on the associated distal humerus fracture)

Intra-operative x-ray of a radial head replacement for an un-reconstructable radial head fracture. 

Distal humerus fractures

These typically result from a fall onto your elbow. Displaced injuries tend to require surgery. Fracture fixation is performed through a 15cm incision over the back of your elbow. Two plates are usually required and your olecranon (proximal ulna) may need to be removed (and re-fixed) to allow access to your fracture.

Risks of surgery include: stiffness (some degree of extension loss is normal), infection, nerve injury, failure of fracture healing, metalwork irritation, arthritis and new bone formation

In rare cases in patients over 65 years old, the destruction is so severe that elbow replacement is considered preferable to attempted fixation

Intra-operative x-ray of a complex distal humerus fixation using two plates to stabilize the joint surface and both columns of the humerus

Olecranon and proximal ulna fractures

Olecranon fractures occur when you land on the tip of your elbow.  If there is significant displacement, or you cannot actively extend your elbow, then you are likely to require surgery.  Many fractures are in only two-pieces and these can normally be repaired using strong suture material or wire that lashes the pieces back together (see fig 4 below). 

Risks of surgery include: stiffness, infection, nerve injury, failure of fracture healing, metalwork irritation requiring removal, arthritis and new bone formation

Displaced Olecranon fracture (left). Same elbow healed after suture-only fixation (right)

Fracture of the proximal ulna with dislocation of the radial head (a Monteggia fracture). Same patient's Intra-operative x-ray with ulna plated and radial head in correct position

Elbow Dislocations

These occur as a result of landing on an outstretched arm, with your body weight causing your elbow to buckle beneath you.  Dislocated elbows require emergency reduction, normally under sedation in the Emergency department. 

Dislocations without fracture generally require a short period of immobilisation (1 week to 10 days) followed by gentle active range of motion.  An MRI may be useful to establish which structures have been injured. Most patients do not require surgery and re-dislocation is rare.  

Dislocations with fractures are more likely to require surgery to restore stability to your elbow.  Very occasionally, an external fixator is also required to hold your elbow in joint while your tissues heal.  After surgery you will begin active range of motion exercises and may be asked to wear a protective brace for 6 weeks

Risks of surgery include: infection, nerve injury, stiffness, failure of fracture healing, metalwork irritation, recurrent instability and new bone formation

Forearm fractures

Forearm (radius and ulna shaft) fractures normally require surgery in adults to optimise rotation of your forearm. In children, more fractures can be treated in plaster, but many still require surgical fixation.  Normally both bones are broken and they are fixed via two incisions, one for each bone. In adults, plates and screws are typically used to achieve accurate position and robust fixation, but in children, either plates or flexible rods may be used.  Metalwork is generally removed in children, typically around six months after injury. 

Risks of surgery include: infection, bleeding, nerve injury, stiffness, new bone formation, metalwork irritation and the fractures not healing or healing in the wrong position

Image opposite - intra-operative x-rays of a child's forearm fracture. The ulna has been plated, but the radius has been fixed with a flexible titanium nail