A broken arm is a common injury. Counting all fractures, about one in every 20 involve the upper arm bone (humerus). Children are more likely to break the lower arm bones (radius and ulna). Falling on an outstretched hand or being in a car crash or some other type of accident is usually the cause of a broken arm. Most people know right away if their arm broke, because there may be a snap or a loud cracking sound. The broken arm may appear deformed and be swollen, bruised and bleeding. A person with a broken arm usually has:

• Extreme pain at the site of the injury.
• Pain increased by any movement.
• Loss of normal use of the arm.

Doctor's treatment

Exam: Tell the doctor exactly what happened. He or she will physically examine the broken arm and check for other injuries, such as nerve damage, which is common with broken arms. The doctor may want to see if the patient can flex and extend the wrist and fingers. Sometimes the doctor may use X-rays or other diagnostic imaging tools to see the bones of both the injured and uninjured arms. If the patient is a child, the long bones of the arm are probably still growing. So the doctor will look carefully for any damage to growth plates.

Reduction: The doctor may need to move pieces of bone back into their correct positions (a process called reduction). Depending upon the severity of injury, the patient may or may not need anesthesia. Those with more serious fractures may require surgery.

Immobilization: With the broken bone back in place, the doctor immobilizes the arm. Most patients get a cast or splint, which holds the bone in good alignment. Alignment of the humerus does not need to be perfect in order to have normal function after healing. The doctor tells the patient how long to wear the cast or splint, usually 2 to 4 months, and removes it at the right time.

Rehabilitation

It may take from several weeks to several months for the broken arm to heal completely. Rehabilitation involves gradually increasing activities to restore muscle strength, joint motion and flexibility. The patient's cooperation is essential to the rehabilitation process. The patient must complete range of motion, strengthening and other exercises prescribed by the doctor. Rehabilitation lasts until tissues perform their functions normally. After rehabilitation, the doctor may want to see the arm again to make sure healing is complete.

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Whether your child is an active athlete or just a toddler jumping on the bed, there's a good possibility that he or she will take a spill at home or on the field or court at some time. These falls are usually harmless; but when a child falls on an outstretched arm, the velocity of the fall combined with the pressure of hitting the ground could be enough to break a bone. That's how most fractures around the elbow joint occur. These fractures account for about 10 percent of all fractures in children.

If your child complains of elbow pain after a fall and refuses to straighten his or her arm, see a doctor immediately. The doctor will first check to see whether there is any damage to the nerves or blood vessels. X-rays will help determine what kind of fracture occurred and whether the bones moved out of place. Because a child's bones are still forming, the doctor may request X-rays of both arms for comparison.

• Above the elbow (supracondylar): The upper arm bone (humerus) breaks, slightly above the elbow. These fractures usually occur in children younger than 8 years of age. This is the most common elbow fracture, and one of the more serious because it can result in nerve damage and impaired circulation.
• At the elbow knob (condylar): This type of fracture occurs through one of the bony knobs (condyles) at the end of the upper arm bone. Most occur through the outer (lateral) knob. These fractures require careful treatment, because they can disrupt both the growth plate (physeal) and the joint surface.
• At the inside of the elbow tip (epicondylar): At the top of each bony knob is a projection called the epicondyle. Fractures at this point usually occur on the inside (medial) epicondyle in children between 9 and 14 years of age.
• Growth plate: The upper arm bone and both lower arm bones have growth plates located near the end of the bone. A fracture that disrupts the growth plate can result in arrested growth and/or deformity if not treated promptly.
• Fracture dislocation: An elbow dislocation can break off the head of the thumb-side lower arm bone (radius), and excessive force can cause a compression fracture to the bone as well. Fractures of the tip (olecranon) of the other lower arm bone (ulna) can also occur.
• Fracture dislocation: A fracture of the inside bone (ulna) can be combined with the top of the thumb-side bone (radius) coming out of the socket at the elbow. This is called a Monteggia fracture. If the dislocation is not seen, and only the fracture is treated, this can lead to permanent impairment of elbow joint function.

Risk factors / prevention

If your child is an active athlete, make sure that he or she wears the proper protective equipment. Elbow guards and pads can help reduce the risk of a fracture above the elbow.

Symptoms

Regardless of where the break is, the symptoms of a broken elbow are similar:

• Acute pain.
• Tenderness.
• Swelling (may be severe or mild).
• Limited movement.

Treatment options

Treatment depends on the type of fracture and the degree of displacement. If there is little or no displacement, the doctor may immobilize the arm in a cast or splint for 3 to 5 weeks. During this time, another set of X-rays may be needed to determine whether the bones are staying properly aligned.

If the fracture forced the bones out of alignment, the doctor will have to manipulate them back into place. Sometimes, this can be done without surgery, but more often, surgery will be needed. Pins, screws or wires are used to hold the bones in place. The child will have to wear a cast for several weeks before the pins are removed. Range of motion exercises can usually begin about a month after surgery.

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Children love to run, hop, skip, jump, and tumble. But if they fall onto an outstretched arm, they could break one or both of the bones in the lower arm. Forearm fractures account for 40 to 50 percent of all childhood fractures. Fractures can occur near the wrist at the farthest (distal) end of the bone, in the middle of the forearm, or near the elbow at the top (proximal) end of the bone.

The bones of the forearm are the radius and the ulna. If you hold your arm naturally by your side, the ulna is the bone closer to you, and the radius is further away. About three out of four forearm fractures in children involve the wrist-end of the radius.

A child's bones begin to heal much more quickly than an adult's bones. If you suspect a fracture, you should obtain prompt medical attention for the child so that the bones can be set for proper healing.

Types of fractures include:

• Torus fracture: Also called a "buckle" fracture. The topmost layer of bone on one side of the bone is compressed, causing the other side to bend away from the growth plate. This is a stable, nondisplaced fracture.
• Metaphyseal fracture: The break is across the shaft of the bone and does not affect the growth plate.
• Greenstick fracture: The break extends through a portion of the bone, causing it to bend on the other side.
• Galeazzi fracture: Affects both lower arm bones; there is usually a displaced fracture in the radius, and a dislocation at the wrist where the radius and ulna come together.
• Monteggia fracture: Affects both lower arm bones; there is usually a fracture in the ulna, and the head of the radius is dislocated. This is a very severe injury and requires urgent care.
• Growth plate fracture: Also called a physeal fracture. The break occurs at or across the growth plate. Usually these fractures affect the growth plate near the wrist on the radius.

The hand, wrist, arm, and elbow can all be injured during a fall on an outstretched arm. To determine exactly what injuries occurred, the doctor will probably want to see X-rays of the elbow and wrist as well as the forearm. The doctor will also test to make sure that the nerves and circulation in the hand and fingers are not affected.

Symptoms

Symptoms of a forearm fracture include:

• Any type of deformity about the elbow, forearm or wrist.
• Acute pain.
• Tenderness.
• Swelling.
• An inability to rotate or turn the forearm.

Treatment options

Treatment depends on the type of fracture and the degree of displacement. If the bones do not break through the skin, the physician may be able to push (manipulate) them into proper alignment without surgery.

Treatment Options: Surgical

Surgery to align the bones and secure them in place may be required if:

• The skin is broken.
• The break is unstable.
• Bone segments have been displaced.
• The bones cannot be aligned properly through manipulation alone.
• The bones have already begun to heal at an angle or in an improper position.
• Most common forearm fracture in adults.

After the bones are aligned, the physician may use pins or a cast to hold them in place until they have healed. A stable fracture such as a buckle fracture may require 3 to 4 weeks in a cast; a more serious injury such as a Monteggia fracture-dislocation may need to be immobilized for 6 to 10 weeks. If the fracture disrupts the growth plate at the end of the bone, the physician will probably want to watch it carefully for several years to ensure that growth proceeds normally. In adults, plates and screws are usually used to hold the bones in proper alignment.

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Distal Humerus Fractures—Fracture of the end of the humerus bone where it forms the elbow is a very severe injury. Damage to the joint and cartilage can lead to elbow stiffness and arthritis. These injuries usually result from severe falls or car accidents.

Signs and symptoms

• Sudden, intense pain.
• Bruising around the elbow.
• Rupture or abrasion of the overlying skin.
• Possible deformity, if there is also a dislocation of the bone.
• Tenderness and swelling over the bone site.
• Numbness in one or more fingers.

Pain with movement of the joint

Evaluation

Your doctor will want to do a careful evaluation of the elbow and hand. Nerve injures are common in these fractures. The elbow is also usually very unstable.

Treatment

Treatment of these injuries is almost always surgical. The surgical repair of these fractures is very difficult, and this is a fracture that is usually best performed by a surgeon who specializes in the treatment of fractures or elbow injuries. After surgery, very aggressive rehabilitation is required to prevent elbow stiffness.

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When you bend your elbow, you can easily feel its "tip," a bony prominence that extends from one of the lower arm bones (the ulna). That tip is called the olecranon (oh-lek'-rah-nun). It is positioned directly under the skin of the elbow, without much protection from muscles or other soft tissues. So it can easily break if you experience a direct blow to the elbow or fall on a bent elbow.

Signs and symptoms

• Sudden, intense pain.
• Bruising around the elbow.
• Rupture or abrasion of the overlying skin.
• Possible deformity, if there is also a dislocation of the bone.
• Tenderness and swelling over the bone site.
• Numbness in one or more fingers.
• Pain with movement of the joint.

Evaluation and classification

It is important to see a physician and verify that there is no associated damage to nerves or blood vessels. Your physician will use X-rays to confirm the diagnosis and classify the type of fracture. Fractures are generally divided into three types, depending on the stability of the joint and the amount of separation among the broken pieces of bone. (Note: Some fractures can have characteristics of more than one category.)

• Type I fractures are generally stable with little displacement. These fractures can generally be treated nonsurgically.
• Type II fractures are the most common. They are relatively stable, although there is displacement of the bone pieces.
• Type III fractures are displaced and involve more than 50 percent of the joint surface, resulting in joint instability.

Treatment

Treatment depends on the type of fracture.

• A type I fracture can usually be treated with a splint or sling to hold the elbow at a 90 degree angle. The physician will request a second set of X-rays after 10 days to make sure that the broken pieces have not become displaced. Gentle motion is permitted, and hand and wrist exercises should be done daily.
• A type II fracture is best treated surgically. The orthopaedic surgeon will use a plate or a combination of wires and pins or screws to hold the bones in place. Physical therapy to maintain range of motion will start a day or two after the operation, and continue for at least six weeks.
• Type III fractures are also treated surgically, usually with a plate that fits under the ulna and around the tip of the elbow. Screws hold the plate in place. You will have to wear a splint for a couple of days, then physical therapy to maintain range of motion will begin.

Fractures of the tip of the olecranon that do not involve the joint may be treated by removing the small fragment and repairing the tendon that has pulled off. Elderly people who experience a type II or type III fracture may be treated with a sling and early range of motion instead of surgery. Athletes who have stress fractures of the olecranon are treated with activity restriction, stretching and range of motion exercises, and substitution activities for 8 to 12 weeks, although complete recovery may take 3 to 6 months.

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Trying to break a fall by putting your hand out in front of you seems almost instinctive. But the force of the fall could travel up your lower forearm bones and dislocate your elbow. It also could break the smaller bone (radius) in the forearm. The breaks can occur at the wrist (Colles fracture), or near the elbow at the radial "head."

Radial head fractures are common injuries, occurring in about 20 percent of all acute elbow injuries. They are more frequent in women than in men and occur most often between 30 and 40 years of age. Approximately 10 percent of all elbow dislocations involve a fracture of the radial head. As the upper arm bone slides back into its appropriate place after the dislocation, it can chip off a piece of the radial head, resulting in a fracture.

Signs and symptoms

If you have any of these signs or symptoms after a fall, see your doctor:

• Pain on the outside of the elbow.
• Swelling in the elbow joint.
• Difficulty in bending or straightening the elbow accompanied by pain.
• Inability or difficulty in turning the forearm (palm up to palm down or vice versa).

Fracture types and treatments

Radial head fractures are classified according to the degree of displacement (movement from the normal position).

Type I fractures are generally small, like cracks, and the bone pieces remain fitted together.

• The fracture may not be visible on initial X-rays, but can usually be seen if the X-ray is taken 3 weeks after the injury.
• Nonsurgical treatment involves using a splint or sling for a few days, followed by early motion.
• If too much motion is attempted too quickly, the bones may shift and become displaced.

Type II fractures are slightly displaced and involve a larger piece of bone.

• If displacement is minimal, splinting for 1 to 2 weeks, followed by range of motion exercises, is usually successful.
• Small fragments may be surgically removed.
• If the fragment is large and can be fitted back to the bone, the orthopaedic surgeon will first attempt to fix it with pins or screws. If this is not possible, however, the surgeon will remove the broken pieces or the radial head.
• For older, less active individuals, the surgeon may simply remove the broken piece, or perhaps the entire radial head.
• The surgeon will also correct any other soft-tissue injury, such as a torn ligament.

Type III fractures have more than three broken pieces of bone, which cannot be fitted back together for healing.

• Usually, there is also significant damage to the joint and ligaments.
• Surgery is always required to remove the broken bits of bone, including the radial head, and repair the soft-tissue damage.
• Early movement to stretch and bend the elbow is necessary to avoid stiffness.
• A prosthesis can be used to prevent deformity if elbow instability is severe.

Even the simplest of fractures will probably result in some loss of extension in the elbow. Also, regardless of the type of fracture or the treatment used, physical therapy will be needed before resuming full activities.

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