Chronic stiffness of the elbow joint is an especially important matter of concern following any type of fracture repair, because it can have such a devastating effect on quality of life.
September 02, 2020
A little elbow grease might be needed to get a job done, but grease will be of no help if you are up to an elbow in pain due to a fracture or dislocation of the joint. “That’s when you have to call an orthopedic specialist,” according to Alejandro Badia MD, noted hand and upper limb specialist and author of the new book Healthcare from the Trenches. He says failure to seek treatment from the right expert can lead to future elbow problems like an unstable, stiff, or poorly functioning joint.
Dr. Badia references the elbow as a “complex hinge,” which, when broken, can pose special challenges for the orthopedic surgeon, including correct identification of “injured structures” inside the joint and determination of the best approach for stabilizing the elbow and preserving its motion.
Experts concur. In a study published a few years ago in the World Journal of Orthopedics, authors contend that “surgical treatments of complex elbow fracture dislocations are among the most challenging procedures… Recognition of the injury pattern and restoration of the joint stability are the prerequisites for any successful treatment of an unstable elbow injury.” Other scientists, writing in RadioGraphics, indicate that “traumatic elbow injuries are commonly encountered in the emergency department setting, but their complexity and clinical significance often go unrecognized.”
“That’s why anyone who believes they have sustained an elbow fracture should quickly seek out an orthopedic specialist and not automatically go to a hospital emergency room for care from physicians who lack specific knowledge of upper-limb joints,” states Dr. Badia, founder and chief medical officer of the Florida-based Badia Hand to Shoulder Center and OrthoNOW®. “The patient can sustain permanent damage to the joint if it is not appropriately treated or treatment is delayed. A trip to the hospital is necessary only when the fracture causes a portion of bone to protrude through the skin (open fracture) or results in a potentially life-threatening complication such as severe bleeding.”
The elbow joint is formed by intersection of three bones – the upper arm bone, or humerus, that extends from the shoulder to the elbow, and the two forearm bones, radius (on the thumb side of the arm) and ulna (on the ‘pinky” finger side). These bones are connected by ligaments, with muscles and tendons stabilizing the joint and allowing the bones to glide around each other like a well-oiled hinge.
“The elbow is critical to arm movement. It is the elbow, working together with the shoulder, wrist, and hand, that makes the arm so versatile. A fracture of that joint can result in significant pain and swelling; limit the arm’s rotation, flexion, and extension; cause numbness in the arm or hand; and damage soft tissue or one or more of the major nerves and blood vessels traveling through the elbow. Oftentimes, surgery is necessary to repair it,” Dr. Badia says.
Falls, especially when they occur with arms outstretched and the hands open, or a direct blow to the elbow as might occur in sports, or car and motorcycle crashes are the most common causes of elbow fractures. In children, elbow fractures, if not correctly addressed, may hinder bone growth and development. The American Academy of Orthopaedic Surgeons reports that as many as 10 percent of all childhood fractures impact the elbow.
Dr. Badia says damage to the radial head – the knobby end of the radius where it meets the joint – is the most frequently occurring elbow fracture, representing about 20 percent of all elbow injuries in adults. Supracondylar breaks – a crack in the humerus just above the elbow – and fractures at the tip of the elbow (medial epicondylar) are more common in children.
Treatment varies depending on severity and complexity of the injury. Non-surgical approaches for small, stable elbow fractures not directly affecting the joint include prescriptive pain medications; placement of the injured arm in a brace, cast or sling to restrict movement; even ultrasound therapy to help bones mend, Dr. Badia says. However, surgery is the likely recourse for displaced elbow fractures — ones that force bones out of alignment, pierce the skin, break a bone into fragments, or affect nerves or blood vessels.
A common surgical approach is open reduction-internal fixation, in which the physician realigns the fractured bones and then permanently fixes them in place with screws, plates or stainless-steel wires, Dr. Badia says. A patient may also require a bone graft, often removed from the hip, to replace a bone fragment lost by injury. The graft eventually fuses to the broken elbow bone, forming one piece. In some cases, such as those involving severely shattered elbow joints or joints affected by osteoporosis, a bone-thinning disorder, partial or total elbow-joint replacement may be necessary. Dr Badia adds, “with complex fractures in the elderly, it is often more prudent to regain elbow motion and independent function with this treatment which allows for early motion within days of the now often outpatient procedure.”
The best therapy, of course, is to take steps that ultimately reduce risk of injury to the elbow and other upper-limb fractures. Dr. Badia offers these tips:
- Warm up the body and upper limbs prior to any intense exercise.
- Use recommended protective gear, such as elbow pads if appropriate, when engaging in sports or other strenuous activities.
- Fall-proof the home. Ensure stairway and walkway lighting is adequate inside and outside the house; re-locate loose rugs, cords and other objects that create a tripping risk.
- Build strong bones through proper nutrition. Exercise regularly.
- Maintain a healthy weight and body mass index. A study by the American Academy of Orthpaedic Surgeons suggests children who are overweight are more likely to sustain complex elbow fractures and experience complications from the injury.
“For the patient, the critical factor, is finding an expert with comprehensive knowledge of the elbow joint,” Dr. Badia emphasizes. “A doctor must be able to understand how best to repair a joint fracture to allow for a fully recoverable union of bone and how to sleuth for more-difficult-to-detect injuries to ligaments, nerves and soft tissue that may have occurred in conjunction with the injury. Chronic stiffness of the elbow joint is an especially important matter of concern following any type of fracture repair, because it can have such a devastating effect on quality of life.”
Bio: Alejandro Badia, MD, FACS, is an internationally renowned hand and upper-limb surgeon and founder of Badia Hand to Shoulder Center and OrthoNOW®, a network of walk-in orthopedic centers. Dr. Badia is the author of Healthcare from the Trenches. http://www.drbadia.com http://www.orthonowcare.com
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