Emergency Medicine

Orthopaedic Emergencies 285

INJURIES TO THE ELBOW AND FOREARM

(a) the capitellum epiphysis is visible by age 1 year, the

medial epicondyle epiphysis by age 6 years, and the lateral

epicondyle epiphysis by age 11 years.

MANAGEMENT

1 Refer all these fractures to the orthopaedic team. The fractures are always
more extensive than they appear on the X-ray, as the structures are mainly
cartilaginous.

Dislocation of the elbow

DIAGNOSIS

1 This is caused by a fall on to the outstretched hand driving the olecranon
posteriorly. Rarely anterior, medial or lateral displacement occurs.

2 The normal ‘equilateral triangle’ between the olecranon and two epicondyles
is disrupted (unlike in a supracondylar fracture).

3 Look for the following complications:
(i) Ulnar nerve damage, causing sensory loss over the medial one-
and-a-half fingers and weakness of the finger adductors, with the
fingers held straight.
(ii) Median nerve damage, causing sensory loss over the radial three-
and-a-half fingers and weakness of the abductor pollicis.
(iii) Brachial artery damage, causing loss of the radial pulse with pain,
pallor, paralysis, paraesthesiae and feeling cold in the forearm or
hand.

4 Request an X-ray that usually shows the dislocation clearly.
(i) Look for associated fractures of the coronoid process of the ulna
or radial head in adults, and of the humeral epicondyles or lateral
condyle in children.

MANAGEMENT

1 Support the elbow in a sling and give morphine 2.5–5 mg i.v. with an
antiemetic such as metoclopramide 10 mg i.v.

2 Call a senior emergency department (ED) doctor to help perform the reduc-
tion under procedural sedation with diazepam 5–10 mg i.v. or midazolam
2.5–5 mg i.v., provided a second doctor is present, and full monitoring and
resuscitation equipment are available.

3 Apply axial traction to the elbow in 30° of extension, and push the olecranon
with the thumbs.

4 Apply a posterior plaster slab with the elbow in 90° of f lexion, and forearm in
neutral position (hand vertical).