Elbow

Activities like climbing trees or attempting to cross the monkey bars, are healthy child’s play and an essential part of development. But as with any physical activity, accidents can happen. Fractures around the elbow are usually caused when a child falls during this type of play and injures one of these three bones; the humerus (upper arm bone), radius or ulna (two bones of the forearm).

Unfortunately, elbow fractures often require surgery since:

  • The fractured pieces are very separate from each other and would heal poorly if left in this position.
  • The fracture crosses into the elbow joint and the bones need to be aligned as perfectly as possible to prevent future arthritis.

Diagnosing an elbow injury in young child can be complicated since their elbow joints are mainly cartilage, making injuries difficult to detect on an X-ray. Further complicating diagnosis, the elbow also has many growth centers that may be injured during a fall. These growth centers ossify (turn to bone) as a child grows and matures, making children’s elbow X-rays at different ages look very different.

Our orthopaedic team is specially trained to diagnose elbow injuries in children, and understands that caring for your child is different than caring for an adult. In fact, we treat more childhood fractures than anyone in the state of Georgia.

Acute Elbow Injuries

Elbow dislocations

An elbow dislocation occurs when the joint between the ulna (long bone in the forearm) and humerus (upper arm bone) comes out of place. This injury:

  • Accounts for roughly three to six percent of pediatric elbow injuries
  • Happens three times as often in boys than girls
  • Is typically seen in children ages 10 to 15
  • Is extremely rare in children younger than age 3

About half the time, the medial epicondyle is also fractured when the elbow dislocates. If there aren’t fractures with the dislocation, the joint is put back in place with your child under sedation, and the elbow is immobilized for around a week. If there is a fracture in addition to the dislocation, surgery may be required.

Regaining range of motion is the biggest obstacle. Elbow dislocations associated with broken bones, especially in adolescent children, have the highest risk of developing stiffness later. Depending on the age of your child and the severity of injury, your doctor may recommend physical therapy to help regain motion. Physical therapy can range from weeks to months.

Elbow dislocation

Lateral condyle fractures

A lateral condyle fracture typically happens when a child breaks a fall with an outstretched hand, fracturing the outside edge of the elbow joint. It’s the second most common elbow fracture in children ages 5 to 10, accounting for 17 to 20 percent of all childhood elbow fractures.

Since lateral condyle fractures often involve both the growth plate and the elbow joint surface, they require surgery to heal properly. During surgery, an incision is made on the outside of the elbow. The fractured pieces are realigned and held in place with pins. A cast is then applied over the pins and remains in place for three to four weeks as your child heals.

Lateral condyle

 

Medial epicondyle fractures

Like other fractures, a medial epicondyle fracture typically occurs due to a fall on an outstretched hand.

It affects the inside portion of the elbow and is often associated with an elbow dislocation. And, when these two injuries occur at once, a bone fragment can get trapped inside the elbow joint.

A medial epicondyle fracture may require surgery, especially if there is fragment entrapment in the joint. If surgery is required, the fragment is moved back into place and fixed with a screw or a pin. If no surgery is required, your child will only need four to six weeks of immobilization in a splint or cast for a full recovery.

Nursemaid's elbow

Nursemaid’s elbow is a common injury that’s usually caused by a sudden pull on a child’s arm. It’s seen in young children ages 2 to 5 most often, since children in this age range have looser ligaments. The injury happens when the radial head (outside of the elbow) is pulled out of joint with the humerus (upper arm bone), trapping one of the ligaments around the elbow.

After this injury, your child can usually bend their arm slightly at the elbow, but probably won’t want to move it. Fortunately, nurse’s elbow is easily corrected by a simple maneuver, and your child can begin using their elbow normally within a few minutes. No further treatment is needed.

Radial head and neck fractures

A radial head and neck fracture is a break to the top of the radius (outside of the elbow) just below the elbow joint. This type of fracture accounts for one to five percent of elbow injuries in children and usually occur in children ages 9 to 10.

When this injury happens, the top of the radius needs to be put back into place, which can usually be done in the emergency room with your child under sedation. The elbow will then be immobilized for approximately one week.

Supracondylar humerus fractures

A supracondylar humerus fracture is a break to the upper arm bone just above the elbow joint. This type of fracture accounts for over half of the fractures around the elbow—and is an injury we treat every day. It’s most common in children ages 5 to 7, since parts of their elbow are still thin and developing, but it is not uncommon outside this age range.

Diagnose
This fracture occurs in the humerus, near the elbow. This is an area of thin, weak bone called the supracondylar region. This fracture can also damage the nerves, blood vessels and muscles surrounding the elbow. Symptoms include severe pain, swelling and inability to move the elbow. Supracondylar fractures need to be evaluated by a pediatric-trained orthopaedist as soon as possible. A specialist can check for damage in soft tissue (blood vessels, nerves and muscles) and for compartment syndrome. Compartment syndrome happens when there is not enough blood supply to a body part after an injury. It can lead to further muscle and nerve damage. Fractured bones need to be aligned for the elbow to function properly. Misalignment can result in deformity and stiffness.

Treat
The treatment for a supracondylar elbow fracture depends on its severity. Many of these fractures are minimally displaced, meaning the bone pieces are relatively close together. If that is the case, we will usually recommend cast treatment for several weeks. However, if the bones are separated far apart from each other and appear crooked on X-rays, your child’s surgeon will likely recommend surgery to help align the bones and maintain the position. Most of the time, no incision will be necessary to realign the bones. Instead, your surgeon will hold the bones in place with two to three sterile metal pins that are placed through the skin, inside the bone and across the fracture. The pins stay outside the skin, but are protected underneath a cast.

After three to four weeks of healing time, we will remove the cast and the pins in our office. This shouldn’t be painful for your child, but we do recommend bringing a distraction–headphones with music, a tablet or phone, or a favorite toy or game. Once the pins are removed, your child will either be placed back in a cast for a few weeks, or more likely, will be allowed to start using their arm.

pediatric fall and elbow fracture illustration
elbow fracture repair illustration

Chronic Elbow Injuries and Conditions

Little league elbow

Little league elbow is an overuse injury caused by repeated throwing without enough rest between throws. During overhead throwing, the cartilage growth plate is placed under stress and becomes irritated, causing pain. The pain may be severe and occur after one hard throw or occur gradually over a season. There may also be swelling, redness or warmth on the injured spot.

Treatment

If a young athlete complains of elbow pain while they throw, have them stop throwing immediately. Apply ice for 10 to 15 minutes and use an ace bandage or compression sleeve to apply light pressure and support. It’s also a good idea to see a doctor for x-rays to check for injury to the growth plate.

Treatment will depend on the extent of the injury to the growth plate. If less severe, continued rest, ice and compression wraps will be the only treatment needed. If the injury to the growth plate is more severe, a cast or surgical pinning may be required.

If recognized early and treated properly, little league elbow usually heals completely and has no long-term effects on the growth plate. But every child and injury is different. A sports medicine physician or sports physical therapist experienced in the rehabilitation of young athletes is the best person to decide when your child is ready to return to their sport. Sometimes, if the injury is minor and caught early, a player will be allowed to bat or play an infield position, such as first base. Other times, the athlete is instructed not to throw at all for several weeks. Once healing is complete, there should be a gradual return to throwing over a period of two to three weeks, and beginning with very light throws from short distances.

Prevention

Count the throws
You can help your young pitcher prevent a throwing injury, like little league elbow, by limiting the number of pitches thrown. Because the number of pitches per inning can vary widely, counting the number of pitches thrown provides the most accurate measure of stress on the shoulder or elbow. Remember to also count hard throws when not pitching (playing infield, throwing at home, pitching lessons).

Recommended maximum pitches by age*:

  • 8-10 years - 40-50 pitches
  • 11-12 years - 55-60 pitches
  • 12-14 years - 60-70 pitches
  • 14+ years - 70-85 pitches

*Make sure your athlete knows to stop throwing at the first sign of pain.

Tips

Unfortunately, there is no way to fully guarantee a young thrower won’t develop an elbow injury, but here are some tips to minimize the risk:

  1. Always warm up before throwing.
  2. Start the season with an evaluation of throwing mechanics by a pitching coach or a physical therapist.
  3. At the first sign of elbow pain, stop throwing and apply ice. When the pain is gone, resume throwing from short distances at half-speed. If the pain persists more than a couple days, or if the pain returns when throwing resumes, see your doctor for an evaluation.
  4. No curve balls or other breaking pitches until age 14. The proper curve ball requires a large enough hand for finger placement across the top of the ball to avoid placing stress on the wrist or elbow. A young pitcher’s hands are too small for proper finger placement—forcing them to twist or torque their wrist and elbow to get the ball to rotate. This increases stress on their inner elbow growth plate.

Ostepchondritis dissecans

Osteochondritis dissecans (OCD) is a painful condition that occurs when lack of blood flow causes bone and cartilage to separate from the surface of a joint. The exact cause is unknown, but family history and repetitive trauma are thought to play a role. While OCD can occur suddenly with a specific traumatic event (such as a fall), it usually develops over time due to repetitive stress on the joint.

OCD lesions are most often seen in active children over age 10—especially baseball pitchers, quarterbacks, gymnasts and swimmers. The repetitive motions associated with these activities exert compressive forces across the lateral (outside) part of the elbow. The first symptom is activity-related elbow pain in the dominant arm. Later symptoms may include catching, locking, grinding and loss of motion.

Treatment
The goal of OCD treatment is to restore normal joint function, decrease pain and reduce the risk of future osteoarthritis in the joint. After examining your child, your doctor may want to do radiology tests, like x-rays or an MRI, to determine the extent of the injury. About 90 percent of the time, resting the joint is all it takes. But every child is different. Depending on the situation, your doctor may also recommend a splint, cast, crutches or physical therapy. Surgery may be required for cases that do not respond to this treatment or are very severe.

Once symptoms are gone and x-rays show the joint is healing, athletes may be ready to slowly progress back to their sport. This is best monitored by a physical therapist.