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Elbow injury
Elbow extension test, fat pads and the radial head fracture.
| If you find… | …then |
|---|---|
| Child with elbow injury after a fall, swelling or deformity | Supracondylar fracture — ED/ortho, check neurovascular |
| Deformity or dislocation | ED reduction |
| Neurovascular deficit (radial pulse, median/ulnar/radial nerve) | ED / ortho now |
| Open wound over the elbow | Open fracture pathway |
- Mechanism: fall on outstretched hand / direct blow
- Hand dominance, job
- Numbness or tingling in the hand
- Previous elbow problems
- Look: swelling, effusion, deformity
- Feel: radial head (lateral, rotate forearm), olecranon, epicondyles
- Elbow extension test: can they fully straighten the elbow?
- Forearm rotation; wrist (Essex-Lopresti) and shoulder
- Distal pulses and nerves
Elbow extension test
Ask them to straighten both arms fully and compare. If an adult can fully extend, a significant fracture is unlikely. If not, X-ray.
Reading the lateral X-ray
A small anterior fat pad is normal. A raised anterior “sail” or any visible posterior fat pad means blood in the joint, so treat as an occult fracture even if no line is seen.
Elbow imaging decision
- Unable to fully extend the elbow
- Bony tenderness (radial head, olecranon, epicondyles)
- Child
- Deformity
Any present: X-ray indicated (elbow AP + lateral). None present: Full extension, no bony signs → no X-ray needed.
Elbow extension test (adults)
- Ask the patient to fully extend both elbows
- Full, symmetrical extension → fracture unlikely
- Unable to fully extend → X-ray
Not validated for children — X-ray injured children with a low threshold.
| Investigation | Only if… |
|---|---|
| Elbow X-ray (AP + lateral) | Unable to fully extend, bony tenderness, or child |
| Look for fat pads | Raised anterior (“sail”) or any posterior fat pad = occult fracture |
Management & advice
- Undisplaced radial head fracture / fat pad with no visible fracture → sling for comfort for a few days, early active movement
- Encourage early movement to avoid stiffness
- Elevate; remove rings
Refer / follow-up
- Radial head fracture / fat pad sign → fracture clinic / virtual fracture clinic
- Displaced fracture, dislocation, child supracondylar → ortho
| Drug | Dose | Duration / notes |
|---|---|---|
| Paracetamol BNF ↗ | 1 g every 4–6 hours, max 4 g in 24 h (reduce if under 50 kg or liver risk) | As needed |
| Ibuprofen BNF ↗ | 400 mg three times a day with food | 3–5 days. Avoid: NSAID-sensitive asthma, GI bleed/ulcer, renal impairment, anticoagulants, heart failure, pregnancy |
There’s a small crack in the top of one of your forearm bones at the elbow. These heal well. The key is to start moving it early so it doesn’t stiffen: use the sling only for comfort for a few days. The fracture clinic will follow you up. Come back if your hand becomes numb, cold or very swollen.
Come back / call 111 — or 999 if severe — if:
- Hand becomes numb, cold, pale, or very swollen
- Pain severe despite painkillers
- Elbow still very stiff after 2 weeks
Official NHS pages. Ask the patient to scan the code with their phone camera, or tap “Show to patient” to make it full screen.
- Immobilising a radial head fracture for weeks (stiffness)
- Missing a supracondylar fracture in a child
- Not checking the wrist (Essex-Lopresti)
Revision practice. Work through a real or imagined case to rehearse the reasoning. It builds a model note to learn from. It doesn’t replace your judgement, your seniors or local guidance.
✎Blank clinic note template
Elbow injury — clinic note
Doses are typical doses drawn from the guidance above. Always confirm in the current BNF/BNFc and your local antimicrobial policy.