Treatment

What treatments should I consider?

Nonsurgical Treatment

For the reasons outlined above, surgery is often the treatment of choice for many elbow fractures. However, some elbow fractures do not require surgery and most often can be treated in a cast. Nondisplaced fractures of the medial epicondyle, lateral epicondyle, or the coronoid process can be treated in a cast. So can minimally-displaced fractures of the radial head or radial neck. The cast serves to protect and immobilize the joint until it is safe to begin elbow movement.

The cast is usually applied from above the elbow to the wrist. If it is necessary or desirable to prevent rotation of the forearm then the wrist should be included in the cast. Often this is not necessary and a simple splint bent at the elbow is enough. There are also many commercially available braces that can be used in place of a cast. Braces and splints allow the arm and elbow to swell without getting compressed inside the cast.

The "bag of bones" philosophy of treatment for severe elbow fractures was common in the past and may still be applied when there are major risks to undertaking surgery. No attempt was made to stabilize the fracture; instead the focus was on regaining as much movement as possible early in the recovery period. Movement gained in the first week after the fracture is hardly ever lost even if the joint is severely disrupted. The bone fragments heal in a position which allows this movement. The elbow function recovered after this type of treatment is never normal and usually is much less than one can expect from surgery.

Surgery

Surgery is recommended for all open fractures, for displaced fractures of the epicondyles and coronoid process, for olecranon fractures, for nearly all intra-articular fractures of the humerus, for Monteggia fractures, and for displaced fractures of the radial head or neck.

Open Fractures. Open fractures will require surgery as soon after the injury as possible. The operation (called debridement) includes cleaning out the wound, removing all dead and contaminated tissue including detached bone fragments, irrigating the wound to remove particles of dirt and drainage. It may not be desirable to close the wound if this would increase the pressure on the recovering tissues. Sometimes special antibiotic beads are placed in the wound to obtain a high local concentration of the drug. In many situations it is appropriate to undertake definitive treatment of the fracture at the same time as the debridement. If this is not possible the wound is cleaned up first and work on the fracture is delayed for several days.

Displaced avulsion fractures. Fractures of the epicondyles and the coronoid process are usually avulsion fractures. This means that the piece of bone was pulled off by a muscle or ligament. Usually, the fracture fragment is still being pulled away from the correct position after the injury. This may prevent the bone from healing back to the correct location. If the bone fragment is not in an adequate position for healing, it should be replaced and fixed by surgery.

In the case of a medial epicondyle fracture, the bone fragment is sometimes trapped in the elbow joint. The joint must be opened up and explored to remove the fragment(s). If these injuries are part of a more complex combined injury, there is even more reason to fix them back in position. After stable fixation of these fragments, the elbow can more safely be moved to prevent stiffness. Activity should be guarded until the bone has healed.

Olecranon Fractures. The fragments of this fracture are nearly always pulled apart by the pull of the triceps muscle. Surgery is indicated to restore the joint surface accurately and to fix the fracture in the reduced position. The olecranon process is just under the skin and easily exposed surgically. The fracture is often held in position by pins and figure-of-eight wire.
The elbow can be protected in a splint for a short period after the operation for comfort, but recovery of early motion without loading the elbow is desirable. The fixation is left in place until the fracture is strongly healed (usually 3 months). If the fixation is irritating or painful it can be removed once the fracture has healed.

Capitellum Fractures. With this injury there is a high likelihood of intra-articular loose bodies which may jam in the elbow joint and damage it. The joint may be opened to retrieve the loose fragments or this may be done with an arthoscope. If the fragment is one large piece and has enough bone attached, it may be possible to fix it back in position with a screw buried into the bony part of the fragment. In this case it is desirable to remove the screw once the fracture has healed. Healing may take some time as the bony part of the fragment has lost its blood supply (avascular) and is dead. The dead bone forms a framework on which new living bone grows to support the joint surface again; this take time. It is not unusual to have a poor long term result from a capitellum fracture with arthritis of this part of the elbow joint.

Intra-Articular Distal Humerus Fractures.
These are the most challenging fractures of the region to treat. Each fracture is different; however the rationale for most fractures is to restore the joint surface exactly then fix the joint to the shaft of the humerus securely. If this part of the reduction is also anatomic it is usually stronger and better fixed but it is not as important as the joint itself and some inaccuracy is permissible. There usually are pins or screws from side to side of the condyles to fix the joint fragments and plates along the columns to fix the joint to the shaft of the humerus.

The fixation should be rigid enough to allow unloaded hinge movement of the elbow joint and rotation of the forearm. The earlier this is achieve the better for the nutrition and recovery of the joint surface. The bone itself takes several months to heal and should not be loaded during this period. Often there are avascularjoint fragments which take a long time to heal fully. The fixation is just beneath the skin; it can be uncomfortable and it is common to remove the fixation once the fracture has healed and good function has been recovered.

Monteggia Fracture of the Ulna. With a Monteggia fracture it is important to reduce the ulna fracture anatomically otherwise the elbow is prone to dislocate again. It is therefore recommended to do an open reduction and internal fixation (ORIF) operation on the bone. The shaft of the ulna lies just under the skin on the back of the forearm and can easily be exposed. The fracture is then brought out to the correct length, alignment and rotation and is then fixed with a plate and screws. Often this treatment is all that is needed for the dislocation but if the radial head or neck is also damaged then this may need treatment also (see next section). One rests one's forearm on the subcutaneous border of the ulna so the plate in this position is often annoying. It is common for the plate to be removed once the injury has recovered and the bone has healed.

Radial Head and Neck Fractures. Many of these fractures do not need surgery. However, where the broken segment of the radial head is large or the amount of angulation or displacement is significant it is better to do an open reduction and internal fixation (ORIF) operation. Because the bone fragments are small and usually have lost their blood supply, this is a challenging operation. The results may not be that good from surgery to repair the fracture. It used to be popular to remove the radial head completely when it was badly injured. This operation has been shown to affect the functioning of the forearm and wrist, so many surgeons attempt to preserve the radial head or replace it with a prosthetic head in some situations. In the case of radial neck fractures, the blood supply of the fragments may be intact. Closed reduction to restore the position may be a good solution as the bone will heal. The problem here is that any residual angulation at the neck may cause problems with rotation of the forearm.

Total Elbow Replacement. Replacing the elbow with an artificial elbow replacement is the "fall-back" operation if treatment of an elbow fracture fails and the elbow is stiff, sore and arthritic. With some very severe elbow fractures one can see "failure" coming right from the beginning. A few surgeons advocate elbow replacement immediately if the elbow is fractured too badly to expect a good outcome with ORIF. If you have pre-existing arthritis of the elbow and a severe injury it may be worth discussing this option with the treating team.

Related Document: A Patient's Guide to Artificial Joint Replacement of the Elbow