Elbow Fractures and Dislocations
What Are Elbow Fractures and Dislocations?
The elbow is a hinge-like joint where three bones meet: the upper arm bone (humerus), the ulna and the rotating bone (radius). An elbow fracture is a break in the continuity of one of these bones, while an elbow dislocation is the separation of the joint surfaces from their normal position. The two can occur together: during a dislocation, fragments of bone can chip off the joint margins. The elbow is one of the large joints that dislocates most often after the shoulder, and which bone, ligament and joint surface the injury involves directly shapes the treatment plan.
Fracture Types and Types of Dislocation
Elbow fractures behave differently depending on the bone involved, and each type has its own treatment logic:
- Radial head fractures: the most common type after a fall onto an outstretched hand; they limit the inward and outward rotation of the forearm (pronation and supination).
- Olecranon fractures: a break of the bony point at the back of the elbow; the pull of the triceps muscle can separate the fragments and impair the ability to actively straighten the elbow.
- Distal humerus fractures: breaks at the lower end of the upper arm bone; they often extend into the joint and are seen both in children and in older adults with weaker bone.
- Coronoid process fractures: a small structure that is a cornerstone of joint stability; if missed, it can lead to recurrent instability.
Dislocations are divided according to whether a bone fracture accompanies them. A simple dislocation involves only ligament and soft-tissue damage, with no bone fracture. A complex dislocation is accompanied by one or more fractures; its best-known example is the “terrible triad”, in which a posterior dislocation occurs together with a radial head fracture and a coronoid fracture, creating marked instability.
What Causes Them and Who Is at Risk?
Elbow fractures and dislocations usually result from a fall onto an outstretched hand, a fall from a height, a traffic or motorcycle accident, or a forceful blow during sport. During a dislocation the ligaments that wrap the joint are stretched or torn, which is why elbow dislocations often occur together with elbow ligament injuries. Older adults with low bone density can sustain a fracture even in a low-energy fall; in active children, the area around the elbow is one of the most common sites of childhood fractures. High-energy sports and motorcycle use markedly raise the risk.
How Do the Symptoms Appear?
The most common symptoms are sudden and severe pain, rapidly developing swelling and bruising. Bending or straightening the elbow and rotating the forearm become markedly limited. In a dislocation there is a visible deformity and the joint looks out of place, with the bony landmarks displaced. In a fracture there is usually point tenderness and sometimes a grating sensation of the bone ends (crepitus). Numbness, tingling or weakness in the hand and fingers can be a sign of nerve involvement.
Why Urgent Assessment Matters
An elbow dislocation and high-energy fractures can be an emergency, because the artery and nerves that pass right beside the joint (the brachial artery and the median, radial and ulnar nerves) can be injured. The first assessment must always check the pulse, the colour and warmth of the hand, capillary refill and the sensation and movement of the fingers. The ulnar nerve, which runs on the inner side, is particularly at risk, and numbness in the hand from pressure in this area can overlap with ulnar nerve compression. Compartment syndrome from progressive swelling is a rare but serious emergency. Reducing the dislocation (putting the joint back in place) should be done in experienced hands; the patient should not try to reduce the dislocation themselves.
What Can It Be Confused With and What Is It Linked To?
A simple strain, a ligament injury or tendinitis can also cause elbow pain; however, a clear deformity, an inability to bear weight through the arm and rapidly developing swelling point toward a fracture or dislocation. Dislocations are often accompanied by elbow ligament injuries and by coronoid or radial head fractures, and if these associated injuries are missed the elbow can remain unstable. Over the long term, damage to the joint surface can pave the way to elbow osteoarthritis and stiffness, that is, permanent loss of movement; stiffness is the most common late complication of elbow fractures and dislocations.
Diagnosis: Examination and Imaging
Diagnosis begins with a detailed history that includes the mechanism and energy of the injury, together with a careful examination. The doctor assesses the deformity, the points of tenderness and the active and passive range of motion, and always performs a neurovascular examination. Two-view X-rays are the first step; in fractures that extend into the joint or are comminuted, computed tomography (CT) clarifies the fracture fragments and the surgical plan. When ligament or cartilage damage is suspected, or when stability after reduction is uncertain, magnetic resonance imaging (MRI) is helpful. Images taken before and after the dislocation is reduced are important to confirm that joint congruity has been restored.
Non-Surgical Treatment
Undisplaced, stable fractures and simple dislocations that remain stable after being reduced are usually treated without surgery. The dislocation is reduced under appropriate sedation or anaesthesia, and the joint is then protected for a short period with a splint or brace. Because prolonged complete immobilisation leads to stiffness of the elbow, early and controlled movement is started as soon as it is safe. In the early period, pain management, ice and control of swelling support the process. Follow-up X-rays are used to confirm that the position of the bone and joint is maintained.
When Is Surgery Needed?
Surgery is considered for displaced or comminuted intra-articular fractures, for olecranon separations, for situations in which coronoid and radial head fractures compromise stability, and for dislocations that remain unstable after reduction (with a tendency to dislocate again). The most commonly used method is open reduction and internal fixation (ORIF): the fracture fragments are anatomically secured with plates, screws or wires. A radial head fracture that is too comminuted to repair may require a prosthesis, torn ligaments may need repair or reconstruction, and complex injuries such as the terrible triad may require repair of the bone and ligaments together. The aim is to provide fixation strong enough to allow early movement.
Recovery and What to Expect
Recovery varies with the severity of the injury and whether it is managed with or without surgery, and it progresses through staged rehabilitation. The priority is early, safe range of motion to prevent elbow stiffness; the elbow is a joint that is highly prone to becoming stiff. As pain and swelling come under control, movement and then gradual strengthening are added; heavy loading and demanding activities are delayed according to bone and tissue healing. The process is guided by goals reached rather than a fixed calendar. If, despite this, permanent loss of movement develops, the advanced approaches discussed under elbow osteoarthritis and stiffness may come into consideration.
Prevention
Not every fracture and dislocation can be prevented, but the risk can be reduced. To lower the risk of falls, home safety, suitable footwear and balance exercises help; to protect bone health, adequate vitamin D and calcium and, when needed, assessment and treatment of osteoporosis are important. Protective equipment and correct technique in sport, along with elbow guards when riding a motorcycle, reduce the likelihood of injury. In children, playground and floor safety also deserve attention.
When Should You See a Doctor?
A clear deformity of the elbow, an inability to bear weight through the arm, rapidly increasing swelling, progressive numbness or weakness in the hand, or pallor, coldness and a change in pulse in the fingers require emergency assessment without delay; these can be a nerve or vascular emergency. Pain and restricted movement that do not settle within a few days and that make daily tasks difficult should also be examined by a specialist. To learn more about injuries in this region you can review our elbow page, and to have an elbow problem evaluated you can contact Assoc. Prof. Serkan Sürücü.