HWN Suggests

Elb-‘ow’! Does my patient with an elbow injury require an x-ray?

There is a rule for that! The elbow extension rule! Simply stated: If a patient with an elbow injury is able to fully extend their elbow, they are unlikely to have a fracture and do not require imaging³.

The “how to”: Provide analgesia to patients, Have patient seated with supinated arms, Have patient flex shoulder to 90 degrees Ask patient to fully extend elbow to either the point of locking or the same level of extension as contralateral side

Of course, no rule is perfect, and the patient should be reassessed later if the following occur: Can no longer fully straighten elbow. Pain is getting worse, Cannot use their arm as previous.

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Featured

 Can’t Miss Elbow Injuries

Approximately 5% of all fractures seen in ED involve the elbow.​ Missed elbow injuries can be highly morbid.

 Elbow Injuries – Ten Pitfalls in Diagnosis and Management

Although it doesn’t get the spotlight much in emergency medicine, the ED diagnosis and management of elbow injuries is of significant clinical importance. There are several easy-to-miss injuries that can lead to functional impairment. Even minor errors in management can result in long term consequences for patients... Keep your differential broad for elbow injuries just like you would with a patient presenting with chest pain.

 How to read an elbow x-ray

Fractures lines can be difficult to visualize after acute elbow injury, particularly in children.

 PEM Playbook – Pediatric Elbow Injuries

The most important pediatric elbow injury is the supracondylar fracture. If you don’t see the obvious fracture, you can be “saved” by the sail sign and/or a posterior fat pad. Also, make sure to look for the anterior humeral line – on the lateral view, a line drawn down the anterior humerus – if it intersects with the middle third of the capitellum, that is normal – it not, suspect a supracondylar fracture. The radiocapetellar line runs along the radial neck through the radial head and should line up nicely with the capitellum. If not, assume a fracture-dislocation.

Articles of Interest

Acute Elbow Injuries and Overuse Disorders

Elbow injuries are common in athletes and occupations that require vigorous physical demands. Occasionally, return to activity prior to complete recovery can lead to chronic complications or other injuries.

Can’t Miss Pediatric Elbow Injuries

With many ossification centers, subtle injuries, and significant consequences, the pediatric elbow x-ray can be challenging but important to interpret.

EM Reflections April 2021 – Elbow Injuries

You examine your patient and they cannot fully extend the elbow, even after pain control. What is the significance of this3? Your patient needs imaging. The ‘elbow extension test’ can help predict the likelihood of fracture. In both adult and pediatric patients presenting within 72 hours of injury, those who could not fully extend the joint had a 48% chance of fracture, while that percentage decreased to 2% if the patient could fully extend the joint.

Episode 61 – The Elbow

We delve into core content on other elbow adjacent injuries using Rosen’s Emergency Medicine (8th edition) Chapter and Tintinalli’s Emergency Medicine (8th edition) Chapter as a guide.

Pediatric Elbow Nightmares

In this video from North York General’s Emergency Medicine Update Conference 2018, Dr. Arun Sayal, an emergency physician who runs a weekly minor fracture clinic at NYGH discusses his approach to pediatric elbow injuries, the importance of good lateral images, common and uncommon missed elbow injuries and clinically important epicondylar fractures that can mimic normal ossification centers.

Resources

StatPearls

Elbow trauma is a common occurrence in children and athletes and can cause a broad array of injury patterns ranging from mild soft tissue injuries and contusions to complex osteoligamentous injuries.