2.6 Elbow and Forearm Fractures

Question 1

Elbow and forearm fractures

• who gets them?
• what are four common patterns/types?

Answer 1

All ages but particularly in younger active patients from high energy trauma.

• Radial head fractures
• Olecranon fractures
• Galeazzi fractures
• Monteggia fractures

Question 2

What are the three joints in the elbow and what movement do they allow?

Answer 2

• radiocapiteller joint which allows flexion/ extension
• humeroulnar which allows flexion/ extension
• proximal radicular joint which allows forearm pronation and supination

Question 3

From proximal to distal what are some important landmarks in the elbow joint?

Answer 3

humerus, capitellum, olecranon, coronoid process of ulna, radial head, ulna

Question 4

What is the most common elbow fracture and how is it sustained?

Answer 4

Radial head fracture

Often from FOOSH

Question 5

What is the pain pattern on a radial head fracture?

What do you need to inspect?

Answer 5

Pain along radial border and pain on forearm pronation.
Severe if there is a tense haematoma (aspirate and inject local anaesthetic).

If it is a displaced radial neck fracture you need to examine the radial nerve function especially the posterior interosseous branch which is a motor branch tested by examining for good power on resisted finger extension.

Question 6

For a radial head fracture what do you look for on xray?

Answer 6

AP and lateral view

Undisplaced fractures can be very hard to see, if normal look for the ‘fat pad sign’ on lateral.
It is a dark triangle in the soft tissue just behind the distal humerus (signifies fat floating on top of blood within the joint capsule).
A dark anterior triangle is normal radial and coronoid fat but if elevated it is pathological.

Question 7

How do you classify radial head fractures?

Answer 7

Mason 1
Mason 2
Mason 3
Good guide to management.

Question 8

What is described in each classification of radial head fractures?

Answer 8

Mason 1 - undisplaced fracture

Mason 2 - displaced fracture with an articular stem >2mm

Mason 3 - displaced comminuted fracture involving the whole of the radial head

Question 9

Management of a radial head fracture?

Based on classifications.

Answer 9

Depends on severity, unless absolutely necessary the elbow should NOT be put into plaster as this leads to post-traumatic stiffness that is irreversible after 2 weeks.

Mason 1
Conservatively managed with early mobilisation. Painful so aspirate and local anaesthetic the haematoma.

Mason 2
Usually require open reduction and external fixation either with plate or screws.

Mason 3
These are unreconstructable and the radial head is excised or replaced with a prosthetic.

Question 10

Longterm outcomes of radial head fractures?

Answer 10

High incidence of stiffness following the injury, even with undisplaced fractures.
Often the final 10-20degrees of extension which is lost. This is an intra-articular fracture so patients may go on to develop post-traumatic arthritis of the radiocapitellar joint.

Question 11

What the the three main mechanisms of olecranon fractures?

Answer 11

Also common

• tension overload from triceps contraction with the elbow flexed
• direct trauma from falling onto the point of the elbow
• chronic overload stress fracture

These are usually isolated injuries but this should not be assumed esp in high energy trauma situation.

Question 12

OE of olecranon fracture?

Xrays of olecranon fracture?

Answer 12

Pain over the elbow and inability to actively extend the elbow against gravity.

On palpation there is sometimes an obvious fracture gap as the olecranon is a very superficial bone.

X-rays are usually very visible on a lateral film.

Question 13

Management of olecranon fractures?

Answer 13

In general they are treated operatively.
Undisplaced can sometimes be treated non operatively but immobilisation with collar and cuff as elbow is intolerant to plaster.

Most common operation for simple fractures is a tension band wire.

Question 14

How does a tension band wire work?

Answer 14

For olecranon fractures. It relies on mobilisation as it transmits the force of triceps to apply compression to the joint side of the fracture (pretty clever).
Comminution of fracture at joint surface? Use open reduction and internal fixation with a plate (no tension).

Question 15

What are Monteggia fractures?

Answer 15

Proximal ulnar fracture with a dislocation of the radial head.
Usually caused by FOOSH with the arm hyperpronated

Question 16

How are Monetggia fractures classified?

Answer 16

Bado classification, according to the direction of the radial head displacement and the apex of the ulna fracture.

Question 17

What is each Bado classification and the direction?

Frequency of each type?

Answer 17

Bado I - anterior (60%)
Bado II - posterior (20%)
Bado III - lateral (15%)
Bado IV - anterior fracture dislocation of radial head and ulna fracture (5%). This is a variant where there is radius fracture too, but remember the ulnar head also needs to be dislocated for it to be a Monteggia fracture.

Question 18

Management of Monteggia fracture?

Answer 18

Open reduction and internal fixation. When ulna fracture is fixed this will reduce and stabilise the dislocated radial head but occasionally this will need a separate open reduction.
Mobilise early to prevent stiffness.

Question 19

What is a Galeazzi fracture?

Answer 19

Think of as opposite to the Monteggia, less common.
Fracture of the radius and a dislocation of the DISTAL radio-ulnar joint (DRUJ).

Caused by FOOSH with forearm hyperpronated.

Question 20

Management of Galeazzi fractures?

Answer 20

As with Monteggia treatment of choice is open reduction and internal fixation (ORIF).
Fixing radius fracture usually reduces DRUJ, if not it may need to be opened and stabilised.