Fractures about the Elbow in Children

Elbow fractures are common in active kids.  The elbow is a particularly complicated joint in children because during growth, much of the ‘bone’ is still made of cartilage, which you can’t see on an x-ray.  Because of this, it is easy to miss minor fractures on an x-ray, and occasionally some more serious injuries.

Evaluation:  The first sign of a significant elbow fracture is pain. Kids will not want to move the elbow, and there may be swelling and bruising or other signs of a significant injury.  With severe injuries, the deformity is obvious.  Thee diagnosis is confirmed with an x-ray.  The tricky thing about elbow fractures in kids is that there are times where the fracture is there but difficult to see on the x-ray.  Sometimes you can only see the swelling in the joint and not the fracture itself.  There are several tricks that doctors will use to sort this out, including taking a comparison view of the other  non-injured side, x-rays from different angles, etc.  Rarely, more advanced studies like an MRI are necessary.

Treatment:  The type of treatment of an elbow fracture in your child depends on the specific type of fracture, its location in the bone and the growth plate, and the potential for healing.  Treatment options range from a simple splint to surgery

Different types of elbow fractures need different treatments.  Here is an overview of some of the common ones.

Supracondylar fractures of the elbow

Supracondylar fractures occur just above the elbow and the growth plate in the end of the humerus.  These fractures occur by over-extending the elbow during a fall.  The most common age is between 5-8 years old, but they can happen at any age.  The trampoline is a particularly common way that this fracture happens.  Severe injuries are dramatic!  The arm looks terrible and the child will be in significant pain.  A trip to the hospital is usually not a difficult decision to make.  Milder forms can be more subtle.  X-rays confirm the diagnosis.

Doctors think about supracondylar fractures as three types; the type determines the type of treatment needed.

Type 1 Fractures:  This is simply a crack in the bone in the supracondylar region.  Although the child will hurt, the bone is basically straight and the fracture is unlikely to change in its alignment.  The concern is that as soon as the child doesn’t hurt anymore, they will return to their normal activities and are at risk of a more severe break…..(see Type III)  These fractures require a cast and are usually healed in about three weeks.  If the cast stays on much longer than that, the elbow can become rather stiff.

This is also an x-ray of a Type 1 Supracondylar fracture of the elbow. This child is older, which makes the fracture lines (indicated by the arrows) easier to see. This type of fracture can also be treated in a cast.

Type 2 Fractures:  This version of the supracondylar fracture is moderately displaced, meaning that the bone will look crooked on the x-ray, but the ends are still attached or “hinged”.  With very minor displacement, these can be gently pushed back into alignment and treated in a cast.  However, if the angulation is significant, the fracture will require an operation and placement of pins to hold the bone in proper alignment.

Type 3:  This is the most severe form of the supracondylar fracture.  The arm will look very crooked and swelling will occur quickly. These fractures are very unstable and always require surgery.

How are Type 3 injuries treated?

Surgery for Type 3 supracondylar fractures has evolved significantly in the past 20 years.  In years past, these fractures were treated with traction in the hospital for as long as three weeks!  (Imagine how your HMO would feel about that….) Although the fractures would heal, the arm often ended up crooked and stiff.  Complications were common. With the development of specialized x-ray equipment known as the “fluoroscope”, surgeons began to treat these fractures be aligning the bones and placing pins to hold the correct position during healing. This is usually done without making an incision (cut) in the skin, which doctors call “percutaneous pinning”. This is now the most common way that these fractures are treated.  Most recently trained orthopedic surgeons are familiar with these techniques.

Most Type 3 supracondylar fractures are treated within 24 hours of the injury.  Your surgeon will want to watch for swelling and other problems for and additional 12-24 hours before sending your child home.  The pins are usually removed in the office at 3-4 weeks after surgery, and the child is allowed to move the elbow.  The goal is to have a completely healed elbow and full range of motion by 6 weeks after the injury.

This next set of pictures illustrates the surgical treatment of a type 3 supracondylar fracture. Pins have been placed across the fracture, and four weeks after surgery there is enough evidence of healing to remove the pins. Once the pins have been removed, the bones will heal the rest of the way.

Complications:  There are several potential things that can go wrong when your child has this fracture.  Some are preventable and others are not.  Your surgeon will be very concerned about making sure that these problems are discovered and treated quickly.

Lateral condyle fractures of the elbow

Lateral condyle fractures involve the growth plate of the end of the humerus and extend into the elbow joint itself.  Therefore, these are very significant injuries.  The problem is that they can be difficult to diagnose because so much of the end of the humerus is cartilage.  This makes the injury hard to see on an x-ray.

Lateral condyle fractures occur after a fall on the outstretched arm.  Pain and swelling are usually immediate, but the arm does not always look crooked.  The diagnosis can usually be made with regular x-rays.  If uncertain, an x-ray of the normal arm may be helpful or views of the elbow at different angles might show the fracture.(

These are called ‘oblique views’ of the elbow)

Treatment:  Most lateral condyle fractures require surgery.   There are several reasons for this.  First, the fracture involves both the growth plate and the joint itself.  For the elbow to grow and function properly, normal alignment must be preserved.  Second, the muscles that help move your wrist are attached to one piece of the fracture. Movement of the will want to pull the fracture piece out of its proper position.  Third, because the fracture fragments are bathed in joint fluid, there is a tendency for the fracture to not heal.  If a “non-union” occurs, it can be very difficult to correct, and will result in long-lasting deformity of the arm.

Monteggia Fractures of the elbow

The term “Monteggia fracture” is used by doctors to describe a specific type of fracture dislocation of the elbow.  In this fracture, there is a break of the upper end of the ulna and a dislocation of the upper in of the radius (known as the radial head) from the elbow.  It is important that the dislocation of the radial head be recognized at the time of the injury.  It is surprisingly easy to miss!

Most Monteggia fractures can be treated by manipulation of the arm under sedation in the emergency room.  However, if a satisfactory alignment of both the radius and the ulna isn’t possible, then surgery may be necessary.

This is an x-ray of a Monteggia fracture. The ulna has been broken and the radial head is dislocated. In the image on the left, the radial head dislocation is shown by the three arrows, and the break in the ulna is shown by the single arrow.

This patient is a little bit older, and also has a Monteggia fracture. The fracture of the ulna is indicated by the two opposing arrows, and the three arrows in a line indicate dislocation of the radial head.

Olecranon Fractures

The olecranon is that hard part of your elbow that is often known as the "funny bone". This bone is commonly broken when a child falls directly onto their elbow. Because this fracture goes through the joint, surgery is often needed to realign the broken pieces of the joint in order to minimize the amount of arthritis that might develop in the joint after the fracture. This set of pictures shows a broken olecranon that has been fixed with a "tension band" technique. This combination of pins and wires is the most commonly used method of fixing olecranon fractures.

After olecranon fractures have healed, if often takes a long time to get all of the motion back in the elbow, and after many fractures it is commonly that there will always be some loss of range of motion when compared to the other side.

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Kidsfractures.com is brought to you by two practicing orthopedic surgeons: John T. Smith MD (Primary Children's Medical Center, Salt Lake City, Utah) and Sohrab Gollogly MD (Monterey Spine and Joint, Monterey, California). This site is for informational purposes only. For a complete explantion of the policy for use of this site, click here.