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Download MBBS Orthopaedics PPT 1 Elbow Injuries Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) Orthopaedics PPT 1 Elbow Injuries Lecture Notes

This post was last modified on 07 April 2022


Elbow Injuries

Objectives

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? Understand the spectrum of Disease
? Common Paediatric fractures
? Common Adult Injuries
? Develop evaluation of elbow injuries
? Diagnose and choose treatment

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Introduction
"Pity the young surgeon whose first case is a fracture around the elbow"

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Question 1- Identify this injury in a 3 years

old boy

a) Dislocation elbow

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b)Supracondylar fracture Humerus

c) Separation distal humeral physis

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d)Lateral condyle Humerus fracture


Introduction- Elbow fractures

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? 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.

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CRITOE

? Capitellum (2years)

? Radius(4years)

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? Internal (or medial) epicondyle(6years)

? Trochlea(8 years)

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? Olecranon(10 years)

? External (or lateral) epicondyle(12

years)

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Common Fractures

? The supracondylar Humerus
? The transphyseal distal Humerus
? The lateral humeral condyle

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? The medial humeral epicondyle (often associated with elbow dislocation)

Uncommon FRACTURES
? The capitellum
? Coronoid

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? Medial condyle
? Lateral epicondyle
? Intracondylar or T-condylar fractures


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Supracondylar Fractures of the Humerus

? Devastating long-term complications.
? Anteriorly- the brachial artery and median nerve
? Laterally, the radial nerve crosses

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? The ulnar nerve passes behind the medial epicondyle

ANATOMY

Coronoid Fossa

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Olecranon Fossa


Classification -Supracondylar fracture

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? Extension type 97.7%

? Flexion type 2.3%
In extension type fracture line runs upwards

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and backwards

And in flexion type it runs downwards and

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backwards

Extension Type Fr

When forced into hyperextension, the olecranon can act as a fulcrum

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through which an extension force can propagate a fracture across the

medial and lateral columns

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Flexion Supraconylar Fr

A posteriorly applied force with the elbow in flexion creates a flexion-

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type supracondylar humeral fracture (arrow).

CLASSIFICATION-Gartland Classification

? After initial classification as either extension or flexion injuries.

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? Classified according to the amount of radiographic displacement.




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Q 2- How Do You Classify?

Flexion/Extension?

Gartland I,I ,I I?

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How Do You Classify?

Flexion/Extension?

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Gartland I,I ,I I?


RADIOGRAPHIC FINDINGS

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? The elbow is painful and difficult to

move

? True AP and lateral radiographs of

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fractures are required

" Bad x-rays lead to bad decisions."

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TREATMENT - Goal

"Avoid catastrophes"

? Vascular compromise

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?Compartment syndrome

"minimize embarrassments"

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?cubitus varus,

?iatrogenic nerve palsies


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Emergency Treatment

? Immobilized - simple splint(radiolucent splint).
? Contraindication- Ischemic hand or tented skin,
? Radiographs should be obtained before splinting,

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or should be used.

If distal extremity is initial y ischemic?

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? Align the fracture fragments
? Re evaluaie vascularity
? Avoid Flexion >90 degrees
Treatment of Nondisplaced Fractures ?

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? Long-arm cast immobilization for 3 weeks .
? Radiographs are repeated at one week ?Check

Extension Gartland III- Treatment?

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Treatment of Displaced Fractures (types II and II ).

? Require reduction.

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? Reduction can be accomplished in closed fashion.

? Maintaining the reduction?

? Cast immobilization, traction, and percutaneous pin

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fixation.

? Adequate closed reduction cannot be achieved- open

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reduction pinning

CR and K-wire fixation
Per op Images

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Healed fracture at 4 weeks
Collateral circulation

Viable hand with abnormal pulses ?

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? Close observation.
? Unidentified vascular pathology-thrombus formation- an

ischemic limb.

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? Pulse oximetry- valuable tool after closed reduction and pinning.
? Pulseless, viable limb-ischemic- arteriography and thrombolytic

therapy
COMPLICATIONS

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Early complications
? Vascular injury
? Peripheral nerve palsies
? Volkmann's ischemia (compartment syndrome).
Late complications

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? Malunion
? Stiffness
? Myositis ossificans.

Vascular Injury-Spectrum?

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? 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

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the anteriorly displaced fragment.

? Indirect injury is usually the result of compression due to the

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swelling.
Management

Thorough assessment of the skin and neurologic status

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If ischemic- manipulated into an extended position.



If fails to provide distal circulation

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Closed reduction and pinning

Reduction of the fracture frequently restores the circulation

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Peripheral Nerve Injury

? 10% to 15% of supracondylar humeral fractures.
? The anterior interosseous nerve is the most commonly

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injured nerve with extension-type supracondylar fractures

? Usually recover spontaneously
? If within 8 to 12 weeks function is not returning-NCV/EMG

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nerve has not been transected.

? Transected- reanastomosis with grafting or tendon transfers


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Compartment Syndrome?

? Best managed by closed reduction and

pinning.

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? A fasciotomy is essential to decompress the

increased pressure

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? Splinting and active and passive range-of-

motion exercises -essential to maintain

joint mobility until function returns.

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Volkmann's Ischemic Contracture (Chr

Compartment Syndrome)

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? Ischemic paralysis and contracture

of the muscles of the forearm and

hand

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? Primarily resulted from obstruction

of arterial blood flow, resulting in

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death of the muscles which get

replaced by fibrous tissue


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Malunion: Cubitus Varus and Cubitus Valgus

? Posteromedially displaced fractures tend to develop Cubitus varus

angulation-more common

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? Posterolaterally displaced fractures tend to develop valgus deviation.

T/T -Osteotomy and k-wire fixation

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Lateral Condyle Fractures

These fractures are the second most

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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

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Treatment

? Undisplaced lateral condyle- Long arm cast.
? Displaced fractures ? stabilized by Open reduction K-wire fixation.

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Complete Articular Fractures of the Distal

Humerus--T-Fracture

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Radial Neck

? 30 of angulation can be treated conservatively provided there is no

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displacement- Long arm cast




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Displaced fractures ?

? Need to be reduced but closed reduction can be difficult

Post Op

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Injuries of Adult Elbow

Spectrum

? Olecranon & Proximal Ulnar Fractures

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? Radial Head Fractures
? Elbow Dislocations
Anatomy-Olecranon Fractures-

? The triceps attaches to the olecranon

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? Principle force which displaces the fracture.

Symptoms

? H/O Trauma: Direct/Indirect

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? Pain
? Swelling
? Inability to extend against gravity
? Tenderness

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Signs

? Swelling
? Contusion

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? Gap at fracture site
? Extension lag

Mayo Classification

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? Type 1: Minimally displaced-Nonoperative

? Type 2: Displaced without ulnohumeral instability-Surgery

? Type 3: Displaced with ulnohumeral instability-Surgery

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OR&IF- Tension band wiring

Post Op

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Complex fractures or fracture-dislocations

? Tension band wire constructs can fail- Plating is the choice

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RADIAL HEAD FRACTURES-Mechanism

? Fractures when it collides with the capitellum
? Fall onto the outstretched hand

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Classification- Mason

? Type 1- Nondisplaced fractures- nonoperative treatment

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? Type 2- Displaced fractures involving part of the radial head- Screws
? Type 3- comminuted fractures -excision

Type 2

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SIMPLE ELBOW

DISLOCATIONS

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? Stable after manipulative reduction.
? Acute redislocations and chronic recurrent dislocations are

uncommon.

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? Mobilization of the elbow within 2 weeks results in less stiffness and

pain

Question 1- Identify this injury in a 3 years

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old boy?

a) Dislocation elbow

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b)Supracondylar fracture Humerus

c) Separation distal humeral physis

d)Lateral condyle Humerus fracture

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