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South Texas Orthopaedics and Sports Medicine
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Copyright 2011 American Academy of Orthopaedic Surgeons
Elbow Fractures in Children

This article is also available in Spanish: Fracturas de los codos en los niñosFracturas de los codos en los niños (topic.cfm?topic=A00488).

Description

Whether your child is an active athlete or just a toddler jumping on the bed, there's a good possibility that he or she will take a spill at home or on the playing field at some time.

These falls are usually harmless. But, when a child falls on an outstretched arm, the velocity of the fall combined with the pressure of hitting the ground could be enough to fracture, or break, a bone around the elbow. That's how most fractures around the elbow joint occur.

Statistics

These fractures that occur in, or around, the elbow account for about 10% of all fractures in children.

Anatomy
The main bones of the elbow, when viewed from the side.

The elbow is a joint made up of three bones. It bends and straightens like a hinge.

  • The humerus is the upper arm bone between the shoulder and the elbow.
  • The radius is one of the forearm bones between the elbow and wrist. When standing with your palm facing up, the radius is on the "thumb side" of the forearm (the lateral side, "outside").
  • The ulna is the other forearm bone between the elbow and wrist, running next to the radius. When standing with your palm facing up, the ulna is on the "pinky side" of the forearm (the medial side, "inside").
Classification

A child can experience a fracture in several places about the elbow, including:

This child has a severe right supracondylar humerus fracture with complete displacement of the fracture fragments.
(Courtesy of Texas Scottish Rite Hospital for Children)

Above the elbow (supracondylar). The upper arm bone (humerus) breaks slightly above the elbow. These fractures usually occur in children younger than eight years of age. This is the most common elbow fracture, and one of the more serious because it can result in nerve damage and impaired circulation.

At the elbow knob (condylar). This type of fracture occurs through one of the bony knobs (condyles) at the end of the upper arm bone. Most occur through the outer (lateral) knob. These fractures require careful treatment, because they can disrupt both the growth plate (physis) and the joint surface.

At the inside of the elbow tip (epicondylar). At the top of each bony knob is a projection called the epicondyle. Fractures at this point usually occur on the inside (medial) epicondyle in children between 9 and 14 years of age.

Growth plate (Physis). The upper arm bone and both forearm bones have growth plates located near the end of the bone. A fracture that disrupts the growth plate (physis) can result in arrested growth and/or deformity if not treated promptly.

Forearm. An elbow dislocation can break off the head of the radius bone, and excessive force can cause a compression fracture to that bone as well. Fractures of the tip (olecranon) of the other forearm bone (ulna) are rare.

Fracture dislocation. The ulna and the radius make up the bones of the forearm and meet the bones of the hand at the wrist. A fracture of the ulna associated with a dislocation of the top of the radius at the elbow is called a Monteggia fracture. If the dislocation is not seen, and only the fracture is treated, this can lead to permanent impairment of elbow joint function.

Risk/Prevention

Many of these elbow injuries occur at playgrounds when children are playing on monkey bars. They lose their grip, slip off, and fall onto an outstretched arm. Please refer to the "Playground Safety Guide" article (listed in the Related Topics section) in order to become familiar with preventive measures when using this equipment.

For younger toddlers, falls from lower heights, such as the bed or couch, are often responsible for elbow fractures as the child puts his/her arm out to break the fall. Parents should discourage bouncing on beds or furniture when toddlers are present.

If your child is an active athlete, make sure that he or she wears the proper protective equipment. Elbow guards and pads can help reduce the risk of a fracture about the elbow.

Symptoms

Regardless of where the break is, the symptoms of a broken elbow are similar.

  • Acute severe pain in the elbow and forearm
  • Occasionally the child will complain of numbness in the hand, if nerve injury has occurred

If your child complains of elbow pain after a fall and refuses to straighten his or her arm, see a doctor immediately.

Doctor Examination / Signs

After discussing your child's symptoms and medical history, your doctor will examine your child's arm.

Around the elbow, there will be

  • Tenderness
  • Swelling (may be severe or mild)
  • Bruising
  • Limited movement
  • Potentially, the hand may be dusky if the circulation has been affected

During the physical examination, your doctor will check to see whether there is any damage to the nerves or blood vessels.

Investigation/Tests

X-rays are necessary. They will determine what kind of fracture occurred and whether the bones moved out of place. Because a child's bones are still forming, your doctor may request x-rays of both arms for comparison.

Treatment
This x-ray shows that the supracondylar humerus fracture has been put into the correct position and held in place with two pins.

Treatment depends on the type of fracture and the degree of displacement. Displacement refers to how far apart the broken ends of the bones are.

Nonsurgical Treatment

If there is little or no displacement, the doctor may immobilize the arm in a cast or splint for 3 to 5 weeks. During this time, another set of x-rays may be needed to determine whether the bones are staying properly aligned.

Surgical Treatment

If the fracture forced the bones out of alignment, the doctor will have to manipulate them back into place. Sometimes, this can be done without surgery, but more often, surgery will be needed. Pins, screws, or wires are used to hold the bones in place.

The child will have to wear a cast for several weeks before the pins are removed. Range of motion exercises can usually begin about a month after surgery.

Longterm Outcome

If the elbow fracture has been placed back together in the normal position, and then fixed with pins temporarily until the ends are healed, then the longterm outcome usually results in a normal functioning elbow. The patient's elbow range of motion returns to normal, or has just a mild limitation.

If the fracture heals in the wrong position, the elbow may remain permanently crooked and have a limited range of motion. It is very important that the elbow be treated correctly at the time of the initial injury.

2011 AAOS Guideline for the Treatment of Pediatric Supracondylar Humerus Fractures

In order to assist doctors in the treatment of children's elbow fractures, the American Academy of Orthopaedic Surgeons has done research to provide some useful guidelines. These are recommendations only and may not apply to each and every individual case.

Guideline on the Treatment of Pediatric Supracondylar Humerus FracturesGuideline on the Treatment of Pediatric Supracondylar Humerus Fractures (http://www.aaos.org/research/guidelines/SupracondylarFracture/SupracondylarFracture_Guideline.asp)

Last reviewed: November 2011

Reviewed by members of POSNA (Pediatric Orthopaedic Society of North America)

AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS "Find an Orthopaedist" program on this website.
Copyright 2011 American Academy of Orthopaedic Surgeons
Related Articles
Care of Casts and Splints (http://orthoinfo.aaos.org/topic.cfm?topic=A00095)
Fracturas de los codos en los niños (http://orthoinfo.aaos.org/topic.cfm?topic=A00488)
Fractures (Broken Bones) (http://orthoinfo.aaos.org/topic.cfm?topic=A00139)
Growth Plate Fractures (http://orthoinfo.aaos.org/topic.cfm?topic=A00040)
Guideline on the Treatment of Pediatric Supracondylar Humerus Fractures (http://www.aaos.org/research/guidelines/SupracondylarFracture/SupracondylarFracture_Guideline.asp)
Internal Fixation for Fractures (http://orthoinfo.aaos.org/topic.cfm?topic=A00196)
Nursemaid's Elbow (http://orthoinfo.aaos.org/topic.cfm?topic=A00717)
Playground Safety Guide (http://orthoinfo.aaos.org/topic.cfm?topic=A00313)
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