Ligament Tears and Elbow Fractures

Fractures about the elbow are the result of high energy injuries.


Fractures about the elbow are the result of high energy injuries.

When a joint is injured, there are a combination of effects:

  • The bone breaks
  • The ligament tears
  • The joint dislocates

The exact injury pattern is dependent on:

  • Amount of force
  • Direction of the force
  • Position of the upper limb at the point of impact.

Types of Ligament Tears

  1. Tearing the outside ligaments, the lateral collateral ligament complex. This occurs when the elbow is excessively bent outward (varus)
  2. Tearing the medial collateral ligament complex. This occurs when the elbow is excessively bent inward (valgus)

Elbow ligament tears usually occur when someone slips and falls forward with the body weight and the momentum being sustained by the elbow.

Usually the ligaments on the outside of the elbow tear first, followed by the force traveling inward on the front and back of the elbow until complete ligament tearing occurs culminating in an elbow dislocation.

When sufficient ligament tearing occurs, and the elbow does not completely dislocate, the elbow experiences signs of instability or slipping out of the joint which includes:

  • A clicking feeling
  • Apprehension or fear of an imminent dislocation
  • A locking sensation when the bone edges wedge on each other

Treatment for Simple Dislocation w/o Associated Fracture

  • Elbow is reduced (put back in place)
  • Rested for a couple of weeks
  • Controlled early motion is then begun with a removable splint placed about 30 degrees of elbow flexion. The splint provides protection from a recurrent dislocation

This treatment works well unless the patient must perform aggressive overhead activity, placing excessive stress on the elbow inside ligaments. In this instance, a ligament reconstruction may be required.


Normal Elbow Supracondylar Supracondylar Low Transcondylar Intercondylar Fracture Fracture Fracture

Elbow Fracture Malunion (Healed poor position) Elbow Fracture Nonunion(Not healed)

The Terrible Triad

The worst of the combined ligament and elbow bone injuries is called the terrible triad:

  • All elbow ligaments are all torn
  • Radial head is broken
  • Part of the ulnar bone called the coronoid process is broken
  • Results in the elbow losing all of the supporting structures keeping the elbow in place

The reconstruction of this fracture pattern requires an experienced elbow surgeon to address the combination of injuries. Elbow fractures can also affect the bones individually. A fracture of the elbow joint can involve:

  • Lower end of the arm bone (humerus)
  • Proximal part of the forearm (radius and ulna)

If an elbow fracture has breached the patients skin, it is called an open fracture. Open fractures are treated as an emergency in order to avoid infection. Considerations for Treatment Decisions

  • Bone quality
  • Pattern of the fracture
  • Separation and angulation of the fracture fragments
  • Extension into the joint surface
  • Amount of fragmentation called “comminution” that has occurred

Without timely treatment for fractures about the elbow, there are side effects. Fractures extending into the joint that are not fixed properly will develop post-traumatic arthritis. Fractures about the elbow that are not treated timely will result in:

  • Stiff elbow
  • Lack of fracture healing called a nonunion
  • Healing of the fracture in the wrong position called a “malunion”


Adult Patients, surgery is always the recommended treatment if an elbow fracture is:

  • Displaced
  • Angulated
  • Fragmented
  • Unstable due to poor bone quality

Children are treated without surgery in most cases because:

  • Their bones heal quicker
  • They have less probability of developing stiff joints after immobilization
  • They have a thicker surrounding layer of perisosteum (lines the bone surface and produces bone). Allowing for the easier manipulation to reduce the fragments back into place

The only time surgery is required for a child is when:

  • Fracture is an open injury
  • There is extension into the joint with displacement present that cannot be put back by closed manipulation
  • There is a vascular (blood supply) compromise

The best options for treating elbow fractures are through the use of plates and screws. There are different types of plate and screw configurations. The evolution of these plate implants include:

  • Pre-contoured plates simulating the normal anatomic curvature of the bone
  • Special screws that not only capture the bone but also lock to the plate thereby enhancing the fixation stability

Qualifying for Immediate Elbow Replacement

When the fracture is a very low supracondylar fracture (shown above) and the quality of the bone is poor or when there is severe fragmentation in an elderly patient with poor bone quality, an immediate elbow replacement is oftentimes the best option instead of an open reduction and internal fixation (ORIF) with plates and screws.