Sports Medicine: Just the Facts

CHAPTER 50 • ELBOW ARTICULAR LESIONS AND FRACTURES 295

2. Volkmann’s contracture can be caused by brachial
   artery injury leading to a severe compartment syn-
   drome, muscle necrosis and degeneration. This
   was often a result of maintaining the arm in severe
   flexion in order to maintain a reduction. A closed
   reduction should be maintained with the arm in 90°
   of flexion. If more flexion is needed to maintain
   the reduction, percutaneous pinning should be con-
   sidered. Treatment options are focused on restor-
   ing vascular flow and reducing compartment
   pressure. It is usually too late to avoid severe mor-
   bidity. It is imperative to avoid this complication
   with proper fracture care and neurovascular moni-
   toring.


3. Arterial injury occurs in approximately 5% of chil-
   dren with supracondylar fractures. Arteriography
   is indicated if the pulse is decreased following
   reduction. If no pulse is present before and after
   reduction, emergent surgery is required, and a
   delay for arteriography is contraindicated.


4. Nerve injuries are usually anterior interosseus or
   radial nerve and can be quite common (up to 50%
   AI injury with type III fractures). Most nerve
   palsies resulting from supracondylar fractures are
   neuropraxias, and will resolve spontaneously
   within 3 to 6 months.

LATERAL EPICONDYLE FRACTURE

• Exceedingly rare in adults (as is the medial epicondyle
  fracture), essentially a pediatric fracture. Intra-articu-
  lar fractures must be considered potentially unstable.
  May need MRI to see intra-articular component of
  fracture. Even benign appearing injuries may have
  high complication rates. Potential complications
  include nonunion, delayed union, and tarda ulnar
  nerve palsy secondary to progressive cubital valgus
  (Wilson et al, 1988).
  •With less than 2 mm of displacement the fracture may
  be treated with cast immobilization, but must be fol-
  lowed closely with serial radiographs. Any displace-
  ment greater than 2 mm must be surgically reduced
  and fixed (Wilson et al, 1988).

MEDIAL EPICONDYLE FRACTURE

• More common in young throwing athletes (i.e., pitch-
  ers) that subject their elbows to high valgus stress. If
  chronic, the condition is termed “Little Leaguer’s
  Elbow.”


• Must perform careful neurologic examination, as
  ulnar nerve may be involved (Wilson et al, 1988).
  
  
  • Must test for stability, as it is possible that elbow dis-
    located and spontaneously reduced, as youths have
    less inherent stability than adults (Fowles, Slimane,
    and Kassab, 1990). Valgus instability should be
    assessed at 25°of flexion. Also gravity stress test may
    be used. The patient lies supine, externally rotate and
    abduct the shoulder to 90°, flex the elbow to 20°, and
    observe for pain and laxity. Stress X-ray views may
    also be performed (Vitale and Skaggs, 2002).
    •Even minimally displaced fractures may be well tol-
    erated in the nonathlete (Wilson et al, 1988). In the
    young athlete that is expected to have valgus stress on
    the elbow (throwers), however, operative intervention
    more likely necessary. Surgical indications include
    the following (Wilson et al, 1988):
    
    
    1. Displacement greater than 10 mm may cause loss
       strength of the flexor mass and should be fixed.
    
    
    2. Ulnar neuropathy with displaced fracture
    
    
    3. Valgus instability as determined above
    
    
    4. Displaced fracture that blocks joint motion
    
    
    
    
  
  
  
  

OLECRANON FRACTURE

• Occur with other elbow fractures 20% of time.


• Displacement of 5 mm or articular step off of 2 mm
  are operative indications. Hardware used depends on
  stability of fracture pattern, with plates used for less
  stable injury.
  •Treat nonoperatively in 20°of flexion to minimize tri-
  ceps pull (Vitale and Skaggs, 2002).

PROXIMAL RADIUS FRACTURE

• Radial neck fractures are more common in 8–12-year
  olds. Treatment determined by angulation. Less than
  30 °angulation of neck is accepted. Greater than 30°
  requires reduction, and greater than 60°may require
  the use of a wire to “joystick” the fracture into posi-
  tion (Vitale and Skaggs, 2002).

ADULT ELBOW TRAUMA

DISTAL HUMERUS FRACTURES

• Rare in the athlete. Requires high energy to cause
  this injury in young adult population. In the general
  population, represent one-third of elbow fractures, or
  2% of all fractures (Scheling, 2002). Have a high
  propensity for stiffness. It is important to maintain a
  functional range of motion for activities of daily
  living.