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Published on March 16, 2016

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ELBOW DISLOCATIONS AND FRACTURES: ELBOW DISLOCATIONS AND FRACTURES THOTTAPLAKKAL JOSEPH BISNY 5 TH YEAR MEDICAL STUDENT DEPARTMENT OF TRAUMATOLOGY & ORTHOPAEDIC SURGERY TBILISI STATE MEDICAL UNIVERSITY , GEORGIA bisnytjoseph22@gmail.com WHAT IS ELBOW FRACTURES AND DISLOCATIONS ???: WHAT IS ELBOW FRACTURES AND DISLOCATIONS ??? ELBOW DISLOCATION : An elbow dislocation occurs when the bones of the forearm (the radius and ulna) move out of place compared with the bone of the upper arm (the humerus ). ELBOW FRACTURE : An elbow fracture is a soft tissue injury with break in one or more of the 3 bones of elbow joint. ANATOMY OF ELBOW : ANATOMY OF ELBOW synovial hinge joint between the  humerus  in the  upper arm and the radius and ulna in the  forearm which allows the hand to be moved towards and away from the body STUCTURES OF ELBOW JOINT (3): STUCTURES OF ELBOW JOINT (3) Humeroulnar joint Simple hinge Flexion & extention Humeroradial joint Ball and socket Pronation and supination Superior radioulnar joint Pivot Freely movable Slide 5: ANATOMICAL LANDMARKS (3) medial epycondyle lateral epycondyle hueters line (triangle –flexion) olecranon process CONTROLS pronation supination flexion extension Movement : flex135 ext 0-5 . Appear in slight valgus {carrying angle}m 5deg/ f10-15. Stability : depend on shape of joint collateral ligaments, capsule& muscles around it ELBOW DISLOCATION: ELBOW DISLOCATION Displacement of elbow joint ETIOLOGY: ETIOLOGY falls onto an outstretched hand. car accidents greater laxity or looseness in ligaments shallow groove in ulnar bone traumatic event. Radial head subluxations in children by pulling the child's arm when the child's elbow is extended. EPIDEMIOLOGY : EPIDEMIOLOGY Second most common dislocation 10 % to 25% of all injuries to the elbow average annual incidence of acute dislocation of 6 per 100,000 population frequently in males 10-50 % are sports related More than 90% of elbow dislocations are posterior dislocations Slide 9: TYPES OF DISLOCATION complete dislocation - the joint surfaces are completely separated . partial dislocation - ( subluxation ) , the joint surfaces are only partly separated Slide 10: DEGREES OF DISLOCATION simple dislocation  does not have any major bone injury.   complex dislocation  can have severe bone, ligament injuries and neurovascular injuries CLASSIFICATION : CLASSIFICATION Based on Direction of displacement STAGES OF SOFT-TISSUE DISRUPTION: STAGES OF SOFT-TISSUE DISRUPTION Stage 1 Disruption of the LUCL Stage 2 Disruption of the other lateral ligamentous structures and the anterior and posterior capsule Stage 3 Disruption of the MCL 3A Partial disruption of the MCL 3B Complete disruption of the MCL 3C Distal humerus stripped of soft tissues SYMPTOMS : SYMPTOMS Severe pain  swelling, inability to bend the arm Loss or abnormal sensation and pulse inability of normal distal arm functions Children with nursemaid's elbow will not bend   due to pain and hold arm slightly bend DIAGNOSIS : DIAGNOSIS HISTORY – MECHANISM OF INJURY describes falling on an outstretched hand ( FOOSH injury ) or other traumatic event CLINICAL EXAMINATION Pulse Touch sensation of digits Motor function -abduction and adduction strength of the digits ( ulnar nerve) opposability of the thumb (median nerve). Posterior elbow dislocations -prominent olecranon and foreshortened forearm Anterior elbow dislocations elongated forearm, arm is held in extension IMAGING STUDIES : IMAGING STUDIES Before reduction of the injury X ray anteroposterior and lateral radiographs CT scanning MRI Ultrasonography Complete dislocation partial dislocation : Complete dislocation partial dislocation DIFFERENTIAL DIAGNOSES : DIFFERENTIAL DIAGNOSES CHRONIC EXERTIONAL COMPARTMENT SYNDROME (CECS) CECS is characterized by exercise-induced pain that is relieved by rest Onset of symptoms at a specific exercise distance or time interval or intensity Compartment pressure readings with and without exercise are the gold standard for the diagnosis  MANAGEMENT : MANAGEMENT Medical management Reduction Surgical Intervention (functional flexion contracture or for chronic residual instability ) Rehabilitation Program Physical Therapy MEDICAL MANAGEMENT : MEDICAL MANAGEMENT  before reduction ANALGESICS Fentanyl ( Duragesic , Sublimaze ) Oxycodone and acetaminophen Acetaminophen and codeine Acetaminophen and hydrocodone ( Vicodin , Hydrocet , Lorcet ) Drug combination indicated for moderate to severe pain. ANXIOLYTIC Midazolam Lorazepam Diazepam TREATMENT -REDUCTION: TREATMENT -REDUCTION Un complicated: - close reduction: traction & counter traction of slightly flexed elbow, correction of lateral displacement & olecranon Pressure. - traction with hyperextion : to unlock olecranon from distal humerus . Reduction Reduction in supine position in prone position : Reduction Reduction in supine position in prone position Slide 22: Complicated : Dislocation with coronoid : treated as before Dislocation with radial head - try to preserve radial head especially if associated with coronoid or medial lig .- by O.R. I.F. - irreducible :-stitch med. lig .& pronater mus - or early excision &immobilization for 3-4 weeks joint unstable --- temporal arthroplasty SURGICAL PROCEDURES: SURGICAL PROCEDURES Block of tibial bone put on coronoid Transfere of biceps tendon to coronoid Creation of cruciating lig . from triceps & bifceps Collateral lig . Reconstruction. LCL + MCL REPAIR: LCL + MCL REPAIR CROSS PINS: CROSS PINS EX-FIX: EX-FIX HINDGED BRACE: HINDGED BRACE COMPLICATIONS : COMPLICATIONS neurovascular compromise c ompartment syndrome loss of ROM. Chronic  regional pain syndrome . Stiffness& post traumatic arthritis . Hetrotopic calcification .(severe inj. long immobilization, aggressive passive motion) . treatment:- NSAID& Radiotherapy -Resection of calcification but delayed till 12 month. -Early resection is contra indicated. -passive motion also avoided. Lock of olecranon Entrapment of in distal humerus median nerve: Lock of olecranon Entrapment of in distal humerus median nerve Recurrent instability: Recurrent instability weak collat. Lig . residual articcular defect in trochlea or trochlear notch ununited coronoid unhealed articular Capsule PROGNOSIS : PROGNOSIS 50 % achieve a full recovery with full ROM . One third of patients experience some limitation of motion at the elbow, usually less than 10° of compromised motion. The remaining 10-15% of patients have more significant losses in function, primarily related to limited ROM . ROM depends on severity of injury Rehabilitation improves outcome PREVENTION : PREVENTION children due to radial head subluxation (nursemaid's elbow) are often preventable by not pulling or lifting on hands Athletes may advised to wear protective gear to prevent elbow injuries. Slide 33: Open / clossed Intra articular and extra articular fractures FRACTURES OF DISTAL HUMERUS: FRACTURES OF DISTAL HUMERUS Mech.of injury : -high energy except in osteoporotic. - fall with flexed elbow > 90 degree. classification [ A O ] - type A: extra articula r - typeB : intra articular unicondylar frct .[one condyle sheared off and the still in contact with the shaft. - typeC : intra articular bicondylar [no one in contact with the shaft] . simple - extraarticular comminution - intraarticular comminution Mechanism of distal humerus fracture : Mechanism of distal humerus fracture classification [ A O ] of distal humerus: classification [ A O ] of distal humerus CLASSIFICATION OF DISTAL HUMERUS : CLASSIFICATION OF DISTAL HUMERUS Fracture of - Supracondylar - Intracondylar - transcondylar - Chondyles [ med.and lat .] - Articular surface[ capitulum and trochlea ] - Epicondyles Diagnosis: Diagnosis C.P : pain , swelling , bruising , deformity Careful neurovascular assessment : ( median & ulnar n . brachial a .) x-ray : APV & LAT.V gentle traction x-ray help in: - - accurate Dx -classification - pre-op. planning C . T MRI Slide 39: X-ray APV Gentle traction x-ray Treatment : Treatment Conservative : -(rare) for undisplaced - p.o.p in 90 flexion for 6-8 w . -weekly x-ray Surgical is the treatment of choice . : because fracture usually unstable Alternative : Surgical treatment: Surgical treatment - internal fixation: it should be early(24-48h)except open fracture , accurate & rigid to give good stability& permit early motion Follow int.fixation: Follow int.fixation O.R.I.F depend on the type of fracture: Clsed fracture: - Uncomminution: screws,K.W (crossed or tension band). - Comminution : plate(single or double). It is the best strong stability . Open fracture : acc.to Gustilo : -G I&II - -------- O.R.I.F early. -G III –------- dibridment & delay O.R.I.F FOLLOW INT.FIXATION: FOLLOW INT.FIXATION Technique : -position : prone, lateral. (help for bone graft) supine (in multitraumtic pat.) - incision : posterior 5cm distal olecranon up to10—12cm above. - isolate ulner n. - Approach Campbell Transolecranon -The medial triceps-elevating exposure for elbow arthroplasty Prone position lateral position: Prone position lateral position Campbell App. Transolecranon APP: Campbell App . Transolecranon APP Advantages and disadvantages : Advantages and disadvantages Campbell app. advantages: Isolate ulnar nerve , no large vessels or nerves in the area of the incision only soft tissue approach to the elbow that expose all the articular surfaces of the joint Transolecranon app. that provides an even better exposure of the articular surface but not give exposure as far proximally as the Campbell app. non union of transolecranon Slide 47: Steps of reduction of intercondylar fracture Reduction & fix . Of condyles : Reduction & fix . Of epicondylar ridge : to the proximal fragment. ( it form a buttress to which condyle later attached) Reduction & fix . Of reassembled condyles : to metaphysis with : screws, K.W or plates. Follow int.fixation: Follow int.fixation Screws: fracture line not extend far proximally. K.Wires : fracture line extend more proximally. Contoured plates(single or double) or Y shape: 1/3 tubular plate in the medial edge of med.pillar . Reconstructive plate in post. Aspect of lat.pillar . Good stability . Tension band wire: Tension band wire Position of plates in distal humerus fracture : Position of plates in distal humerus fracture post surgical : post surgical Light Splint after 3 weeks splint removed and the arm is supported by a sling Start gentle active exercise vigorous motion contraindicated Slide 53: Alternative treatment indications -severe fracture - severe soft tissue damage. - unstable Patient - lack of expertise & facilities - severe osteoporosis Alternative treatment : Alternative treatment Types : Bones bags :arm held in a collar &cuff , flexion >90 . active motion encouraged if possible exercise continue after healing ROM after :(45—90 ) Olecnon traction Ilizarof external fix . (hinged type). Total elbow arthroplasty .( eldery&less active pt ) Olecnon traction. Ilizarof ext. fix. (hinged ) : Olecnon traction . Ilizarof ext. fix. (hinged ) Ilizarof ext. fix. (hinged ) Total elbow arthroplasty: Ilizarof ext. fix. (hinged ) Total elbow arthroplasty SIDE SWIPE FRACTURE: SIDE SWIPE FRACTURE - occure in arm protruded from window of car --fracture always open . Vary from GI ---- GIII - the most combination of this fracture consist of: * open distal 1/3 of olecranon . * anterior dislocation of redial head & distal fragment of ulna . * comminuted distal humerous fracture . &other Slide 58: Above epycondyles 80 % extention type , 20 % fle xion Common in child ren Types – 1 undisplaced partial displaced Fully displaced TRANSCHONDYLAR FRACTURE : TRANSCHONDYLAR FRACTURE Unstable unite slowly if treated conservatively . - percutaneous pins , lag screw (through small incision without opening the frac .), or canulated screw . - intraarticular and not fixed properly -complicated by avascular necrosis -Displaced fracture ------ O.R.I.F. Undisplaced transcondylar f. Avascular necrosis: Undisplaced transcondylar f. Avascular necrosis Slide 61: Treated by : reduction of dislocation ,O.R. I. F . of olecranon fracture & ext. fix. To stabilize the all complex. Primary goal : care of open wound &restoration of elbow joint. Always complicated by infection, non union severe myositis ossificans arthroplasty Displaced transcondylar fracture : Displaced transcondylar fracture Complication of intercondylar fracture : Complication of intercondylar fracture Early : neurovascular injury. Late : -Failure of fixation. -Non union & malunion . - Non union of olecranon osteotomy . -Infection. -Nerve palsy. - Hetrotopic ossification. Failure of fixation. Nonunion Hetrotopic ossification : Failure of fixation. Nonunion Hetrotopic ossification Fracture of capitulum : Fracture of capitulum - Mech. Of injuiry : F.O.S.H---- head of radius impacted to capitulum ----fracture classification: - type I : large fragment of bone and articular surface (involve trochlea ) are fractured. - type II : small shell of bone and articular surface (not involve trochlia ) - type III: comminuted fracture Classification of capitulum Fracture : Classification of capitulum Fracture Slide 67: Diagnosis:- x-ray :lateral view (diagnostic). & A.P.V Deff . diag .: fracture of radial head but the later rarely to displaced anteriorlly C.T scan Treatment: ( through lat. Approach) Type I : O.R.I. F with small AO screw or Herbert's screw ( from post. to ant.) Type II&III : excision . -A fter treatment: like intercondylar fractures Fracture of capitulum Lat.V APV : Fracture of capitulum Lat.V APV Treatment of capitulum Fracture : Treatment of capitulum Fracture Screw countersinked posteriorly. Not damage articular surface anteriorly. EPICONDYLAR FRACTURES : EPICONDYLAR FRACTURES Med.& Lat. Epic . Fractures rare in adult. Mech. Of injury : direct blow. Treatment: - lat. Epic. - Usually conservative : p.o.p for 3w. followed by supportive motion. - Med Epic. - Undisplaced : p.o.p . - displaced>1cm:O.R.I.F. -if med.epi. displaced to joint in: (rare in adult). 1.close Red: vulgus of elbow, arm supination & ext . of wrest. 2. open Red. OLECRANON FRACTURES: OLECRANON FRACTURES Mech. Of inj . : direct : blow on elbow. indirect : falling on partially flexed elbow with indirect force generated by triceps ___ avulsion. classification : type I : proximal 1/3. type II :middle 1/3 . type III : distal 1/3 . it may be associated with ant. displacement of radius. Classification of Olecranon fractures : Classification of Olecranon fractures I II III Slide 73: Other classification: [Colton ] according to: displacement and the anatomy of the fracture, thus give guidance as to the appropriate type of fixation : I.Nondisplaced and stable II.Displaced fractures - Avulsion fractures - oblique fractures . - Transverse fractures - Isolated comminuted fractures - Fracture/dislocations classification of olecranon fracture [Colton]: classification of olecranon fracture [Colton] Treatment: Treatment I.Nondisplaced and Stable : - fractures displacement <2 mm. - no change in position with gentle flexion to 90 degrees or with extension against gravity . -treated by: p.o.p in 90 degrees of flexion for 3 to 4 w -followed by protected range of motion. -avoiding flexion past 90 degrees until bone healing is complete radiographically usually around 6 to 8 weeks. -In the elderly patient , motion may be initiated earlier than 3 weeks if the patient can tolerate it. -Control x-Ray after 5-7d. - P.o.p in full extension avoided b/s lead to stiffness Nondisplaced and Stable: Nondisplaced and Stable Slide 77: Displaced Fractures : O.R.I.F is the treatment of choice. The goals of treatment are: 1.Maintain power of elbow extension. 2.Restore congruity of the articular surface. 3.Restore stability of the elbow. 4.Prevent stiffness of the joint. 5.Allow the patient to do early motion Slide 78: Avulsion fracture : -tension band wire. (T.BW) - if fragment small--- excision . Transverse fracture: Without comminution : tension band wire is suitable - if fragment is big----- cancellous screw 6.5mm -if fragment is small --- Kirschner Wires with comminution : contoured plate with or without bone graft ( T.B.W cause compression at fracture site & narrowing of trochlear notch.) Avulsion fracture : small fragment: Avulsion fracture : small fragment Transverse fracture without comminution: Transverse fracture without comminution Slide 81: Oblique fracture without comminu :( T.BW may displace) T.B.W with Interfragmentery screw with comminution : plate with bone graft. Slide 82: Isolated comminution : results from direct trauma. There are multiple fracture planes, &crushing of many fragments. -may be associated with fractures of the distal end of the humerus , the radial & ulnar shafts, and the radial head. -If no association with previous excision. - if association occur (excision unsuitable)--- combination of plate & tension band wire . Excision of proximal fragment:: Excision of proximal fragment: Advantages : The possibility of non union is eliminated. The possibility of traumatic artheritis is minimised due to irregular articular surface. Indication: severely comminuted fractures in which open reduction and internal fixation are not Possible. -non articular #. -Non union . -after failed O.R.I.F . -when reduction is delayed 10—14d. -in type III open# or if local soft tissue damaged . Contraindication : in distal 1/3 olecranon # joint instbility Technique excision of proximal fragment: Technique excision of proximal fragment After excision of proximal fragment: After excision of proximal fragment - p.o.p in flexion 70 deg. For 3w. - gentle motion when wound heal permit 7—10d. -avoid forceful movement (ext. or flex.) for 3 month. Slide 86: Fracture-Dislocation Fracture-dislocations present a challenging problem because of the combination of severe bone and soft tissue damage ORIF with restoration of alignment and stability of the ulna is the goal This can be achieved by - intramedullary wires or a long screw to ulnar canal Often plate is required in spite of such soft tissue damage carefully considered . ------- joint instability Complication of olecranon fracture: Complication of olecranon fracture the most common complication are: -nonunion. -Limitation of motion (esp. extension). -Subcutaneous pain due to fixation devices. After treatment of olecranon fracture: After treatment of olecranon fracture P.o.p at 90degree for 3—4w. When wound heal permit, (7-10) gentle exercise. Periodic removing of p.o.p . Maximal function not return before 6—12m. CORONOID FRACTURE: CORONOID FRACTURE It indicate severe trauma to elbow. Mech. of inj. - Struck of trochlea in coronoid . -avulsion (less common). Classification Morrey and Regan : type I: simple avulsion of tip. type II: involve <50%. type III :involve >50%. Treatment: typeI&II : heavy suture to the proximal of ulna. typeIII :I . with screw. O’Driscoll’s Classification: O’Driscoll’s Classification Coronoid fracture Classification Treatment : Coronoid fracture Classification Treatment FRACTURE OF RADIAL HEAD : FRACTURE OF RADIAL HEAD It is common in adult. Mech.of inj. :F.O.S.H while arm pronated , head impacted in capitulum . Classification Mason : type I: nondisplaced . type II: displaced. typeIII : Comminuted. type IV : fracture with post. Elbow dislocation & coroniod fracture Masons classification : Masons classification Slide 94: Treatment: conservative : -type I. -type II : - <1/3 of head circum. -in outer part. - or get 70% of pronation & supination . Slide 95: surgical [ Excision of radial head] is the treatment of choice. Indication: typeIII head become oval in shape. >1/3 of head circumflex involve lie in the inner side. loss fragments in the joint. f. neck with enough angulation that interfere with rotation. Excision of radial head: Excision of radial head Technique: -excision should be early 24—48h. -incision:5cm below radial head up to lat. condyle . -pass b/n E.C.U&E.D or E.C.U&anconeus . -excision: transverse just proximal biceptal tuber. - anular lig should be excised. & debris removed After treatment: p.o.p in90 deg.for 1w then converted to sling till 3w. Within this interval start gentle active motion. Site of excision of radial head: Site of excision of radial head Slide 98: segment is large, isolated& uncomminuted fixed with : screw . fracture of radial head & neck with elbow dislocation & coronoid fracture (type IV): : fracture of radial head & neck with elbow dislocation & coronoid fracture (type IV): - f. coronoid undisp .----- excision early. - f.coronoid disp . but not commin - ---- O.R.I.F of coronoid f & excision of head at the same time. - coronoid f with commin &difficult to fix it wait 3-6month - healing - excision . FRACTURE OF RADIAL NECK: FRACTURE OF RADIAL NECK Radial neck classified same as# of head. treatment: -conservative: undisp . or minimally displaced. -surgical: excision of head for severely displaced. if joint unstable ----- small T plate. or small cortical screw in oblique # . small T plate. small cortical screw in oblique # : small T plate. small cortical screw in oblique # Combined fracture and dislocations : Combined fracture and dislocations Monteggia – radial head dislocation + ulnar shaft fracture Galeazzi – distal radial head displacement + distal radial fracture Essex lopresti – radial head fracture + subluxation or dislocation of radioulnar joint Terrible triad – radial head fracture + MCL tear + coronoid process fracture ESSEX- LOPRESTI FRACTURE DISLOCATION) : ESSEX- LOPRESTI FRACTURE DISLOCATION) Mech. Of inj .:F.O.S.H cause disruption of distal radio ulner j &tearing of interosseus memb .---radial migration Diagnosis: wrist pain associated with displaced radial head or neck fracture treat early - migration occurrs – poor outcome Treatment :O.R. I.F of proximal radial + pinning of distal R.U.J In supination . pin removed after 3—6 w. irreducible fracture --- radial head arthroplsty . Essex- Lopresti fracture dislocation: Essex- Lopresti fracture dislocation PROGNOSIS : PROGNOSIS Depends on severity of injury Patient status Quality of treatment Reference : Reference HTTP://ORTHOINFO.AAOS.ORG/TOPIC.CFM?TOPIC=A00029 HTTP://ORTHOINFO.AAOS.ORG/TOPIC.CFM?TOPIC=A00503 ELBOW INJURIES AND FRACTURES HTTP://PATIENT.INFO/DOCTOR/ELBOW-INJURIES-AND-FRACTURES ELBOW DISLOCATIONS HTTP://WWW.EMEDICINEHEALTH.COM/ELBOW_DISLOCATION/PAGE3_EM.HTM#ELBOW_DISLOCATION_SYMPTOMS_AND_SIGNS HTTP://EMEDICINE.MEDSCAPE.COM/ARTICLE/96758-FOLLOWUP#E6 DISLOCATIONS OF THE ELBOW APRIL D. ARMSTRONG, BSC(PT), MD, MSC, FRCSC HTTP://WWW5.AAOS.ORG/OKO/EM_DOCS/EBOOKS/COR2/SAMPLE_CHAPTER_3.PDF COMMON FOREARM FRACTURES IN ADULTS HTTP://WWW.AAFP.ORG/AFP/2009/1115/P1096.HTML THANK YOU !!!!: THANK YOU !!!!

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