The history includes a description of the mechanisms of the traumatic event, pain characteristics including quality, duration, location, effects of movement, exacerbating or alleviating factors, severity, and radiation, in addition to concomitant injury or systemic complaint. Past medical history should include occupational factors and prior or chronic problems with the affected joint or other bones or joints. Numbness or weakness distal to the injury may indicate neurovascular injury. Pediatric orthopedic injuries, including those caused by abuse, are discussed in Chapter 160 , Chapter 172 .

Examination begins with simple inspection and comparison with the contralateral limb. The position in which the extremity is held should be noted. Deformity may indicate fracture, dislocation, or hematoma. Range of motion may be evaluated, depending on the appearance of the extremity and suspicion of injury, but general manipulation of the acute injured extremity should be minimized. Bony prominences are palpated with notation of specific areas of tenderness. Crepitus, bony deformity, and pain in an acutely injured limb are virtually diagnostic of a fracture. The radial head specifically is palpated for tenderness. Intra-articular elbow fractures, including those of the radial head, are universally associated with effusion (hemarthrosis). Elbow effusions are notoriously difficult to discern on examination but are readily identified on lateral radiographs ( Fig. 44.5 ). The extremity should be inspected for swelling, compromised circulation, or any wound that may indicate an open fracture.

(A) Anterior and posterior fat pads on lateral study (arrows) . (B) The anterior fat pad is normally a thin radiolucent stripe; the posterior fat pad is not visible. (C) An effusion displaces both fat pads. This posterior fat pad is now visible.

In addition to the elbow region itself, focused examination incudes a thorough evaluation of the distal neurovascular status of the extremity. The presence of the brachial, radial, and ulnar pulses is confirmed by palpation. The ulnar pulse is more difficult to palpate than the radial pulse and may not be palpable in some normally healthy, uninjured patients. The radial, median, and ulnar nerve all transit the elbow in close proximity to major bony structures, so their motor and sensory functions require meticulous evaluation. The radial nerve can be tested by evaluating sensation to the dorsum of the hand and wrist extension. The median nerve should be tested for sensory function by assessing sensation at the lateral aspect of the thumb and for motor function by having the patient perform an “okay sign.” The ulnar nerve provides sensation to the palmar aspect of the small digit and motor function to the medial interosseous muscles, which can be tested by having the patient abduct the small finger from the ring finger against pressure.

When movement of the elbow is possible without significant pain, the range of motion of the elbow in all planes (i.e., flexion-extension and pronation-supination) is determined. Inability to tolerate even minimal passive movement often indicates dislocation or fracture. With the forearm supinated, the normal range of motion is 0 degrees in full extension to 150 degrees in full flexion. A mild degree of hyperextension is normal in some individuals and should be symmetric. With the elbow flexed at 90 degrees and the thumb facing up, the forearm normally supinates and pronates 90 degrees. Range-of-motion testing may be limited by pain and nearly impossible with severe injuries. These examination maneuvers can be delayed until after radiographic evaluation.

Injuries in the region of the shaft of the humerus and regions of the elbow fall into several categories including fractures, dislocations, subluxations, and soft tissue disorders ( Table 44.1 ).

Most elbow and humerus injuries are evaluated radiographically, although on occasion, history and clinical examination alone are sufficient to make a diagnosis (e.g., minor mechanical fall with minimal pain, full range of motion, and no significant bony tenderness). There are no validated clinical decision rules for the elbow, so radiography should be performed when there is moderate to severe pain, significant limitation in range of motion, obvious deformity, swelling or effusion, or significant tenderness over any of the bony prominences or the radial head. With the exception of children with an apparent nursemaids’ elbow (radial head subluxation), radiography should be used in virtually all pediatric elbow injuries with any bony tenderness on examination to assess for possible growth plate injury.

Routine views of the elbow include at least the anteroposterior and lateral views, with oblique views when indicated. Anteroposterior and oblique views are taken with the elbow extended. The lateral view is taken with the elbow in 90 degrees of flexion and the thumb pointing upward. Positioning of the elbow is critical because anything other than a true lateral view makes accurate interpretation of soft tissue findings and alignment difficult.

Most fractures in the elbow region are identifiable on plain film, but radial head and subtle supracondylar fractures may be difficult to visualize. Radiographic examination of the elbow for the presence of fat pads secondary to traumatic effusion provides additional clues. The normal cortex of the radius is smooth and has a gentle continuous concave sweep. If consistent with history and physical findings, any disruption of this smooth arc is considered evidence of fracture. Abnormalities within the soft tissues on elbow films are particularly important and may be the only radiographic sign of a fracture. Normally, fat surrounding the proximal elbow joint is hidden in the concavity of the olecranon and coronoid fossae. The elbow normally has a narrow strip of lucency anteriorly, parallel to the anterior surface of the distal humerus (the anterior fat pad). The presence of a posterior fat pad is not considered a normal finding. Injuries that produce intra-articular hemorrhage cause distention of the synovium and displace the fat out of the fossa, making the posterior fat pad visible on lateral radiographic views. This intra-articular swelling displaces the anterior fat farther anteriorly, where it takes the shape of a main sail of a boat. Thus, this radiographic finding is commonly referred to as the “ sail sign .” Displacement of the posterior fat pad makes it visible on the lateral radiograph as a “posterior fat pad sign” (see Fig. 44.5 ). In the setting of trauma, more than 95% of patients with a posterior fat pad sign have an intra-articular skeletal injury. These soft tissue findings occur even with subtle fractures, and when present in the setting of trauma, an occult fracture should be suspected. In adults without an identifiable fracture on radiograph, fat pad signs most often indicate a radial head fracture, whereas in children a supracondylar fracture is the more likely. In the absence of trauma, the presence of a fat pad suggests other causes of effusion (e.g., inflammation or infection). Of note, the fat pad sign may be absent in fractures where the injury is severe enough to rupture the capsule.

Additional imaging modalities in the emergency department (ED), such as diagnostic ultrasound, computed tomography (CT) scanning, or magnetic resonance imaging (MRI) may be considered. Ultrasound may be considered as a quick bedside modality to assist in the diagnosis of fractures, most easily utilized on long bone injuries. This may be especially useful in the hemodynamically unstable trauma patient during resuscitation. MRI (or less commonly) CT imaging may be considered if there is high suspicion for a fracture on plain imaging that only reveals a traumatic effusion. Classically, this may be applied to pediatric elbow injuries to identify underlying fractures not visible on standard imaging.

General management should begin with an appropriate evaluation for additional traumatic injuries, pain control with appropriate analgesics, and attempt at providing patient comfort with support for the injured extremity. Once a potential fracture is identified, prompt neurovascular evaluation should be performed. Although a warm hand with normal color suggests adequate tissue perfusion, a handheld Doppler device is often required to evaluate major vessel flow if significant swelling is present or if the pulses are not palpable. Poor perfusion may be the result of a direct arterial injury, compression or kinking from a fracture or dislocation, or compartment syndrome. Identification of arterial compromise or injury warrants consultation with an orthopedic or vascular surgeon (see Chapter 40 ). Compartment syndrome is discussed in Chapter 41 . Orthopedic consultation and measurement of compartment pressures is indicated for patients who are suspected of having a compartment syndrome.

General disposition for patients with humerus or elbow fractures depends on several considerations. Common fracture factors include need for emergent operative intervention and need for neurovascular checks or compartment checks. Additionally, patient-centered factors may include pain control, ability to perform activities of daily life, and ability to follow instructions regarding fracture care. Given the previous factors, a large proportion of upper extremity, humerus, and elbow injuries can be discharged home with appropriate orthopedic specialty follow-up.

Specific Fractures

Shaft of the Humerus

Clinical features of humeral shaft fractures

Fractures of the humeral shaft commonly result from a direct blow to the arm, severe twisting, or a fall on an outstretched hand. Rarely, fractures may be caused by abrupt muscle contraction, such as occurs when a javelin or baseball is thrown. The shaft of the humerus most commonly fractures in the middle third in a transverse fashion. The patient reports localized pain, which is often severe in nature, and the arm is visibly swollen and cannot be used. When a fracture is complete, bony crepitus is felt in the shaft of the humerus with the slightest manipulation of the arm. The arm may be shortened or rotated, depending on the displacement of the fracture fragments. When the fracture is incomplete, there is bony tenderness and swelling without obvious deformity.

Diagnostic testing for humeral shaft fractures

Imaging studies should routinely include the shoulder and elbow joints. The humerus is a common site for benign tumors, unicameral cysts, and primary bone malignancies, as well as a common site for metastatic disease. Thinning of the cortex and abnormal osteoblastic or osteoclastic activity are evidence of a pathologic fracture ( Fig. 44.6 ). Pathologic lesions may require orthopedic surgical intervention, though once a fracture occurs, a multidisciplinary approach with oncology should occur to determine the best course of surgical intervention. While these fractures may be stabilized with treatment such as plates, pins, intramedullary nails, cement, and joint replacement, these underlying fractures do not heal well without concomitant treatment of the underlying pathologic condition.

Pathologic Fracture of Proximal Humerus.

Management of humeral shaft fractures

Isolated, closed fractures are treated with a high degree of success. Attempts at fracture reduction and external immobilization are generally unnecessary and may be detrimental to healing. Fractures that are nondisplaced or minimally displaced are immobilized by adding a coaptation, or “sugar-tong” splint, to the sling and swathe ( Fig. 44.7 ). The coaptation splint is often replaced by a functional brace after the first 10 to 14 days. If the fracture is grossly displaced or comminuted, the hanging cast technique is preferable. This technique is especially effective with spiral fractures ( Fig. 44.8 ). Care is taken not to make the cast too heavy because this would distract fracture fragments or too tight as this may compromise circulation. The hanging cast has the disadvantage of using gravity for traction and requires that the patient remain upright at all times, including during sleep, a situation that many patients find intolerable. Neurovascular examination should be repeated and documented before and after the application of any splint or cast because entrapment of the nerve between fragments can occur after these interventions. Open reduction and internal fixation ( Fig. 44.9 ) are necessary for open fractures, presence of multiple injuries that preclude mobilization, bilateral fractures, poor reduction, poor patient compliance, failure of closed treatment, and fractures through pathologic bone. Although the success rate with nonoperative intervention is about 80%, patients should be included in treatment decisions regarding nonoperative versus operative intervention because operative intervention may decrease recovery time resulting in earlier return to work.

Sugar-Tong Splint for Humeral Shaft Fractures.

Gentle traction is applied (1) as the splint is placed (2) from over the deltoid laterally, under the elbow, and up into the axilla. An elastic wrap holds the splint in place (3). The axilla must be padded (4), and a sling is used (5).

Adapted from Connolly JF. DePalma’s management of fractures and dislocations . Philadelphia, PA: WB Saunders; 1981.

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