Elbow

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.

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.

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 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.

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.

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.

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.

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.

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.