Cite This Article

What is the diagnosis?

Left sided floating elbow, a finding to describe a humerus with concomitant radius/ulnar fracture on the same side (notably w/ previous ORIF to forearms as well). Here, a distracted and displaced left humeral fracture accompanies a midshaft radial and ulnar fracture. On exam, this patient also demonstrated a radial nerve palsy with inability to extend at the wrist or thumb though radial pulses were strong and palpable. 

This fracture pattern was initially described in pediatric patients with supracondylar fractures with associated forearm fractures [1].

What is the mechanism of injury?

Typically seen in high impact traumatic injuries such as FOOSH, fall from height, and MVCs as is demonstrated in this patient.

What physical exam findings are expected?

As with other fractures, you may see obvious fracture deformities from high impact mechanisms with tenderness and swelling at the fracture site. Studies have shown that approximately 50% of these types of fracture patterns are open and many have concomitant nerve injury with the most common being the radial nerve. They may demonstrate weakness or inability to extend at the wrist or thumb. Though lower risk, injuries should also be evaluated for vascular compromise with the brachial artery being the most often lacerated vascular structure [2].

• Pearl: Studies have suggested poorer functional outcomes with nerve injuries despite surgical management [3]. 

What imaging modalities can be used?

X-rays are initially used for diagnosis. The entire left upper extremity was imaged in this case. CT angiography should be used to evaluate if there is concern for vascular injury and can also better characterize the fracture pattern for pre-operative planning. 

What is the management in the ED/when should you consult orthopedics?

Orthopedics should be consulted for surgical management once a floating elbow fracture is identified as surgery is required for definitive management. Many of these fractures are open and require washout. Though compartment syndrome is rare, it should be considered given the severity of these fractures. In the Emergency Department, splinting should be carefully placed to immobilize the forearm and humerus dependent on the fracture pattern. 

• Pearl: Though no standardized splinting has been suggested, sugar tongs with a coaptation splint, double sugar tongs, and posterior long arm splints would be acceptable as was done in this case prior to surgery.