Q: I broke my elbow and they say I will need surgery to fix it. Why can’t I just have a cast for a couple of months?
A: The elbow is basically a ‘hinge’ joint, with the distal end of the humerus (the upper arm bone) acting like the ‘ball’ that fits into the ‘socket’ of the forearm’s proximal ulna (the olecranon). The third bone in the forearm, the radius, acts like a golf tee (the disk-like proximal end is called the radial head) for part of the ‘ball’ of the humerus to sit on, allowing the elbow to rotate (to turn the palm up and down). There are also many muscles, tendons, ligaments and other soft tissue structures that make up the elbow.
Elbow fractures are fairly common, accounting for up to 5 percent of all fractures in adults. They can occur due to direct trauma, such as falling onto/directly hitting the elbow (the most common way the olecranon is fractured), or when someone breaks their fall using their outstretched hand with the force of the fall transmitted up the forearm to the elbow (the most common way the radial head is broken).
An elbow fracture may involve any or all of the structures described above. The details of the injury help inform what treatment(s) may be required.
Radial head fractures may be classified by Mason Type:
Mason Type I is non-or minimally displaced (the bones are in correct anatomical alignment) and is the type that may not require surgery
Mason Type II is displaced more than 2 millimeters
Mason Type III are comminuted (broken into several fragments)
Mason Type IV where the fracture is associated with a dislocation.
The important factors of an olecranon fracture also include whether or not the fracture is displaced and/or comminuted.
The symptoms of an elbow fracture depend on the type and severity of the injury. Severe disruption of the anatomy (dislocation or significantly displaced fractures) may be immediately visually obvious. More subtle fractures (such as a non-displaced ‘crack’ in the bone) may present with pain plus/minus swelling. Compromise of any of the nerves that pass through the elbow (such as the ulnar nerve, sometimes called the ‘funny bone’ where it wraps around the elbow) can affect the fingers and/or hand.
The evaluation of a suspected elbow fracture requires X-rays to visualize the bones. Depending on the specifics, a CT scan may be recommended, and it is usually needed to help guide the planning for which surgical approach is the best treatment.
The initial treatment of an elbow fracture is immobilization (usually with a splint or cast), ice (to reduce pain and swelling) and pain medication. An open fracture, where the bone protrudes through the skin, is a medical emergency requiring immediate intervention.
The goal of treatment of an elbow fracture is to retain function of the joint. Non-surgical treatment may be all that is required for fractures where the bones are not displaced or comminuted and there are no other indications requiring surgery (such as other injuries that would compromise function); the splint may need to be left in place for 6 weeks or longer to allow complete healing. For the injuries requiring surgery, the specific surgical intervention that is best is determined by the details of the injury. In many cases, screws, plates and/or other hardware (called open reduction and internal fixation) may be required to restore anatomic alignment and function.
Potential complications of elbow surgery include infection, irritation from any hardware implanted, damage to nerves/blood vessels/other structures, and/or failure to restore correct anatomic alignment. Any of these complications may require further treatment, even including further surgery. Late complications may include post-traumatic arthritis.
Even after successful surgery, further treatment is required. Specifically, rehab is needed to help the patient regain range of motion (although some permanent loss of range of motion is not uncommon) and strength in their muscles (unused muscles, due to limitations of using the arm while the bones heal, atrophy quite rapidly). This requires occupational and physical therapy exercises for months until recovery is complete.
Jeff Hersh, Ph.D., M.D., can be reached at DrHersh@juno.com