Download MBBS (Bachelor of Medicine, Bachelor of Surgery) Orthopaedics PPT 1 Elbow Injuries Lecture Notes
Elbow Injuries
Objectives
? Understand the spectrum of Disease
? Common Paediatric fractures
? Common Adult Injuries
? Develop evaluation of elbow injuries
? Diagnose and choose treatment
Introduction
"Pity the young surgeon whose first case is a fracture around the elbow"
Question 1- Identify this injury in a 3 years
old boy
a) Dislocation elbow
b)Supracondylar fracture Humerus
c) Separation distal humeral physis
d)Lateral condyle Humerus fracture
Introduction- Elbow fractures
? 5% to 10% of all fractures in children are fractures of the elbow.
? High potential for complications-difficult to manage.
? Supracondylar fractures- 50% to 70% of all elbow fractures
? Frequently in children between the ages of 3- 10 years.
CRITOE
? Capitellum (2years)
? Radius(4years)
? Internal (or medial) epicondyle(6years)
? Trochlea(8 years)
? Olecranon(10 years)
? External (or lateral) epicondyle(12
years)
Common Fractures
? The supracondylar Humerus
? The transphyseal distal Humerus
? The lateral humeral condyle
? The medial humeral epicondyle (often associated with elbow dislocation)
Uncommon FRACTURES
? The capitellum
? Coronoid
? Medial condyle
? Lateral epicondyle
? Intracondylar or T-condylar fractures
Supracondylar Fractures of the Humerus
? Devastating long-term complications.
? Anteriorly- the brachial artery and median nerve
? Laterally, the radial nerve crosses
? The ulnar nerve passes behind the medial epicondyle
ANATOMY
Coronoid Fossa
Olecranon Fossa
Classification -Supracondylar fracture
? Extension type 97.7%
? Flexion type 2.3%
In extension type fracture line runs upwards
and backwards
And in flexion type it runs downwards and
backwards
Extension Type Fr
When forced into hyperextension, the olecranon can act as a fulcrum
through which an extension force can propagate a fracture across the
medial and lateral columns
Flexion Supraconylar Fr
A posteriorly applied force with the elbow in flexion creates a flexion-
type supracondylar humeral fracture (arrow).
CLASSIFICATION-Gartland Classification
? After initial classification as either extension or flexion injuries.
? Classified according to the amount of radiographic displacement.
Q 2- How Do You Classify?
Flexion/Extension?
Gartland I,I ,I I?
How Do You Classify?
Flexion/Extension?
Gartland I,I ,I I?
RADIOGRAPHIC FINDINGS
? The elbow is painful and difficult to
move
? True AP and lateral radiographs of
fractures are required
" Bad x-rays lead to bad decisions."
TREATMENT - Goal
"Avoid catastrophes"
? Vascular compromise
?Compartment syndrome
"minimize embarrassments"
?cubitus varus,
?iatrogenic nerve palsies
Emergency Treatment
? Immobilized - simple splint(radiolucent splint).
? Contraindication- Ischemic hand or tented skin,
? Radiographs should be obtained before splinting,
or should be used.
If distal extremity is initial y ischemic?
? Align the fracture fragments
? Re evaluaie vascularity
? Avoid Flexion >90 degrees
Treatment of Nondisplaced Fractures ?
? Long-arm cast immobilization for 3 weeks .
? Radiographs are repeated at one week ?Check
Extension Gartland III- Treatment?
Treatment of Displaced Fractures (types II and II ).
? Require reduction.
? Reduction can be accomplished in closed fashion.
? Maintaining the reduction?
? Cast immobilization, traction, and percutaneous pin
fixation.
? Adequate closed reduction cannot be achieved- open
reduction pinning
CR and K-wire fixation
Per op Images
Healed fracture at 4 weeks
Collateral circulation
Viable hand with abnormal pulses ?
? Close observation.
? Unidentified vascular pathology-thrombus formation- an
ischemic limb.
? Pulse oximetry- valuable tool after closed reduction and pinning.
? Pulseless, viable limb-ischemic- arteriography and thrombolytic
therapy
COMPLICATIONS
Early complications
? Vascular injury
? Peripheral nerve palsies
? Volkmann's ischemia (compartment syndrome).
Late complications
? Malunion
? Stiffness
? Myositis ossificans.
Vascular Injury-Spectrum?
? A diminished pulse/Without a pulse/With an ischemic limb.
? Complete transection of the brachial artery
? An intimal tear
? Compression either between the fracture fragments or over
the anteriorly displaced fragment.
? Indirect injury is usually the result of compression due to the
swelling.
Management
Thorough assessment of the skin and neurologic status
If ischemic- manipulated into an extended position.
If fails to provide distal circulation
Closed reduction and pinning
Reduction of the fracture frequently restores the circulation
Peripheral Nerve Injury
? 10% to 15% of supracondylar humeral fractures.
? The anterior interosseous nerve is the most commonly
injured nerve with extension-type supracondylar fractures
? Usually recover spontaneously
? If within 8 to 12 weeks function is not returning-NCV/EMG
nerve has not been transected.
? Transected- reanastomosis with grafting or tendon transfers
Compartment Syndrome?
? Best managed by closed reduction and
pinning.
? A fasciotomy is essential to decompress the
increased pressure
? Splinting and active and passive range-of-
motion exercises -essential to maintain
joint mobility until function returns.
Volkmann's Ischemic Contracture (Chr
Compartment Syndrome)
? Ischemic paralysis and contracture
of the muscles of the forearm and
hand
? Primarily resulted from obstruction
of arterial blood flow, resulting in
death of the muscles which get
replaced by fibrous tissue
Malunion: Cubitus Varus and Cubitus Valgus
? Posteromedially displaced fractures tend to develop Cubitus varus
angulation-more common
? Posterolaterally displaced fractures tend to develop valgus deviation.
T/T -Osteotomy and k-wire fixation
Lateral Condyle Fractures
These fractures are the second most
common children's
elbow fracture to need operative treatment.
(1) The fracture heals slowly.
(2) Late deformity can occur.
(3) Non-union is a recognized complication
Treatment
? Undisplaced lateral condyle- Long arm cast.
? Displaced fractures ? stabilized by Open reduction K-wire fixation.
Complete Articular Fractures of the Distal
Humerus--T-Fracture
Radial Neck
? 30 of angulation can be treated conservatively provided there is no
displacement- Long arm cast
Displaced fractures ?
? Need to be reduced but closed reduction can be difficult
Post Op
Injuries of Adult Elbow
Spectrum
? Olecranon & Proximal Ulnar Fractures
? Radial Head Fractures
? Elbow Dislocations
Anatomy-Olecranon Fractures-
? The triceps attaches to the olecranon
? Principle force which displaces the fracture.
Symptoms
? H/O Trauma: Direct/Indirect
? Pain
? Swelling
? Inability to extend against gravity
? Tenderness
Signs
? Swelling
? Contusion
? Gap at fracture site
? Extension lag
Mayo Classification
? Type 1: Minimally displaced-Nonoperative
? Type 2: Displaced without ulnohumeral instability-Surgery
? Type 3: Displaced with ulnohumeral instability-Surgery
OR&IF- Tension band wiring
Post Op
Complex fractures or fracture-dislocations
? Tension band wire constructs can fail- Plating is the choice
RADIAL HEAD FRACTURES-Mechanism
? Fractures when it collides with the capitellum
? Fall onto the outstretched hand
Classification- Mason
? Type 1- Nondisplaced fractures- nonoperative treatment
? Type 2- Displaced fractures involving part of the radial head- Screws
? Type 3- comminuted fractures -excision
Type 2
SIMPLE ELBOW
DISLOCATIONS
? Stable after manipulative reduction.
? Acute redislocations and chronic recurrent dislocations are
uncommon.
? Mobilization of the elbow within 2 weeks results in less stiffness and
pain
Question 1- Identify this injury in a 3 years
old boy?
a) Dislocation elbow
b)Supracondylar fracture Humerus
c) Separation distal humeral physis
d)Lateral condyle Humerus fracture
This post was last modified on 07 April 2022