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Fatima Al Ghaithi Case Serise March  2nd
 

Fatima Al Ghaithi Case Serise March 2nd

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Elbows Injuries

Elbows Injuries

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    Fatima Al Ghaithi Case Serise March  2nd Fatima Al Ghaithi Case Serise March 2nd Presentation Transcript

    • HUMERUS AND ELBOW
      • By: Fatma Al-Ghaithi
      • mentor: Dr. Asma Al-Balushi
    • HUMERUS AND ELBOW
      • Anatomy
      • Fractures:
      • -shaft of humerus
      • -distal humerus
      • -radial head
      • -ulner
      • Management
      • Dislocations and sublaxation
      • Soft tissue disorders
    • Anatomy of the humerus
    •  
    •  
      • All of the following are true except:
      • A-the wrist flexors originate from the medial epicondyle.
      • B-the only 2 structures contained in the posterior compartment are the triceps muscle and the ulner nerve.
      • C-median nerve symptoms may develop if supracondylar process fractured, which is a variant in some people.
      • D-the most vulnerable structure for injury in midshaft humeral fracture is the radial nerve.
      • All of the following are true except:
      • A-the wrist flexors originate from the medial epicondyle.
      • B-the only 2 structures contained in the posterior compartment are the triceps muscle and the ulner nerve. (radial n)
      • C-median nerve symptoms may develop if supracondylar process fractured, which is a variant in some people.
      • D-the most vulnerable structure for injury in midshaft humeral fracture is the radial nerve.
    • Compartments of the arm
      • 1) The anterior compartment contains three muscles:
      • -the biceps, the brachialis, and the coracobrachialis.
      • -the brachial artery.
      • -median nerve, musculocutaneous nerve, and ulnar nerve.
      • 2) the posterior compartment contains:
      • -the triceps
      • - radial nerve .
    • Clinical features history
      • pain
      • Past medical history
      • occupational factors
      • mechanism of injury
      • numbness or weakness
    •  
    • Humeral shaft #
      • The most common site is the middle one 3ed.
      • The most common associated injury is the radial n. (often is neuropraxia, resolves spontaneously).
    • Humeral Shaft Fractures
    • Management of humeral shaft #
      • Nonoperative.
      • 1)Coaptation (sugar tong) splint + sling for nondisplaced.(for 10-14 days)
      • 2)Hanging cast: displaced or comminuted #.
      • Operative for:
      • -open #
      • Multiple injuries that preclude mobalization.
      • b/l fracture
      • Poor reduction
      • Poor pt. compliance.
      • Failure of closed treatment.
      • Pathological #.
      • *** isolatead radial n. injury is not an indication of operation.
    • Supracondylar fractures
      • Two types:
      • 1)supracondylar extension #.
      • 2)supracondylar flexion #.
      • All of the following statements regarding supracondylar extension fractures are true except:
      • They generally result from a fall on the outstretched arm.
      • They are more common in adults than in children.
      • They are associated with the development of Volkmann’s ischemic contracture.
      • Associated median nerve injury may occur with this injury.
      • All of the following statements regarding supracondylar extension fractures are true except:
      • They generally result from a fall on the outstretched arm.
      • They are more common in adults than in children.
      • They are associated with the development of Volkmann’s ischemic contracture.
      • Associated median nerve injury may occur with this injury.
    • What is the peak age incidence for this type of fracture?
      • The peak incidence of supracondylar fracture is in children 5 to 10 yrs.
    • Radiological findings
      • Anterior fat pad.
      • Posterior fat pad.
      • Anterior humeral line.
      • Radial head contour.
      • Ossification centers. CRITOE
      • Hourglass sign.
      • Distal humerus.
      • Ulna/Olecranon.
      • Clinical correlation.
      • symmetric figure of eight/hourglass sign at the distal humerus; also notice the posterior fat pad?
      • Anterior and posterior fat pad signs
    • .
      • This radiograph demonstrates abnormal alignment of the anterior humeral line strongly suspicious for fracture. (The anterior humeral line of a toddler/child must also intersect the middle third of an ossified capitellum; also note the posterior fat pad and sail sign.)
    • This radiograph depicts a normal anterior humeral line
    • Here is a radiograph with both a sail and posterior fat pad sign . Posterior fat pad is never normal and always signifies fluid in the intraarticular space. in the setting of trauma, this strongly implies fracture of an articular surface.
    • Gartland Classification for Extension-Type Supracondylar Fractures Marx: Rosen's Emergency Medicine, 7th ed B: Posterolateral rotation of the distal fragment A: Posteromedial rotation of the distal fragment Displaced fracture with no cortical contact Type III Displaced fracture with intact posterior cortex Type II Nondisplaced fracture Type 1
    • Flexion Elbow extended, S-shaped configuration presentation Type II: manipulated into extension then immobilized by long arm cast or with percutaneous pins. Type III: open reduction. Nondisplaced: splint or cast flexed to 90. Minimal Displaced: splint or cast, 110-120 flexion. Total displacement: prompt reduction, followed by percutaneous pin fixation or internal fixation management Increase angulation. the anterior humeral line intersect the capitellum either normally or posteriorly. Posterior fat pad Abnormal anterior humeral line X-ray findings Ulner n. injury (the most common injury) Stiffness of the joint. Cubitus valgus. brachial a. and median n. injuries, compartment syndrome (Volkmann’s ischemic contracture). Cubitus varus deformity. complications Direct blow to the posterior aspect of flexed elbow. Fall on outstretched hand. Mechanism of injury Supracondylar flexion # supracondylar extension #.
    • supracondylar extension #.
    • Steps in reduction of a displaced supracondylar fracture
    • Tips for reduction and immobilizing distal humerus #
      • With minimally displaced supracondylar #, the greater the flexion at elbow, the greater the chance of vascular impairment. so we flex it to 110-120.
      • Medially displaced # are immobilized with forearm pronated, and laterally displaced # is immobilized in supination.
      • What is shown in this x-ray:
      • A) normal x-ray
      • B) radial head sublaxation
      • C) supracondylar fracture
      • Supracondylar fracture.
      • 1. Anterior fat pad, Posterior fat pad,
      • 2. Anterior humeral line: Abnormal.
      • 3. Radial head contour: Normal.
      • 4. Distal humerus: Abnormal. The metaphysis of the distal humerus on the AP view shows two irregularities.
      • 5. Ulna/Olecranon: normal
    • ?
    • Joint effusion. No visible fracture
      • 1. Anterior fat pad
      • 2. Posterior fat pad
      • 3. Anterior humeral line: Normal.
      • 4. Radial head: Normal.
      • 5. Ossification centers: The capitellum and radial head centers are ossified.
      • 6. Hourglass sign: Absent. This indicates that the lateral view is oblique.
      • 7. Distal humerus: No irregularities seen.
      • 8. Ulna/Olecranon: Normal.
    • Transcondylar and intercondylar
      • Both more common in elderly.
      • Neurovascular complications in intercondylar fractures are not common.
      • Difficult to heal and treat:
      • -open reduction, internal fixation.
      • -early mobilization.
    •  
    • condylar # in children
      • Lateral condyle are the 2ed most common # in children involving the elbow joint after extension supracondylar #.
      • Medial condyle # are rare.
      • Management: -closed reduction/cast <2 ml displacement.
      • -closed reduction/pin
      • fixation (3-4 weeks) >2 mm
    • Medial epicondyle epiphysis (arrow) trapped within the elbow joint following avulsion
      • All of the following are true regarding olecranon # except”
      • Occur more common in children than adults.
      • Displacement of > 2 cm is considered an indication for surgery.
      • The most vulnerable structure to injury is the ulner n.
      • The anatomic integrity of the olecranon is essential for triceps strength and normal function of the elbow.
      • All of the following are true regarding olecranon # except”
      • Occur more common in children than adults.
      • Displacement of > 2 cm is considered an indication for surgery.
      • The most vulnerable structure to injury is the ulner n.
      • The anatomic integrity of the olecranon is essential for triceps strength and normal function of the elbow,
    •  
    • little Leaguer's elbow
      • trauma to immature epiphyses by repetitive throwing.
      • Avulsion of the medial epicondyle or compression fracture of the subchondral bone of the lateral condyle or radial head.
      • This diagnosis should be sought in an athletic adolescent with medial epicondyle or radial head pain in the absence of acute injury by history.
      • Adolescents with this condition should be forced to rest the elbow.
    • ?
    • Impression: Joint effusion. Ulna fracture.
      • Anterior fat pad: Abnormal.
      • Posterior fat pad: Present,
      • Anterior humeral line: Normal.
      • Radial head: Normal.
      • Ossification centers: Only the capitellum is ossified.
      • Hourglass sign: Although the lateral view appears to be somewhat oblique, an hourglass sign is present.
      • Distal humerus: No irregularities seen.
      • Ulna/Olecranon: Linear lucency down the center of the long axis of the ulna best seen on the AP view.
    • ?
    • Radial head fracture
    •  
    • Radial head fracture
      • Type I: undisplaced fractures
      • Type II: marginal fractures (involving <30% of the articular surface) with displacement
      • Type III: comminuted fractures. 
      • Type IV: any of the above with elbow dislocation
    • Radial head fracture
      • Management:
      • Type I: sling, early mobilization (24-48 hrs), aspiration of hemarthrosis and injection of bupivacaine.
      • Type II: as above or: radial head excision
      • Type III: radial head excision
      • Type IV: treat dislocation and type of radial head in jury present accordingly.
    • Elbow dislocation
      • Is the 2ed most common large joint dislocating after the shoulder joint.
      • most often dislocates posteriorly, although it may dislocate anteriorly, medially, or laterally.
      • Posterior dislocations are reduced with an assistant immobilizing the humerus and applying countertraction while traction is applied to the distal forearm. The ideal position is for the elbow to be flexed at 30 degrees with the forearm supinated while distal traction is applied .
    • Post reduction management
      • immobilization in a sling and posterior splint.
      • apply ice, elevate, gentle range-of-motion exercise in 3 to 5 days.
      • The most serious complication of elbow dislocation is vascular compromise. Severe disruption results in injury to the brachial artery in 8% of cases.
    • Complete dislocation of the elbow . Ulnar coronoid process fractures are often associated with this injury.
    • Subluxation of the Radial Head (Nursemaid’s Elbow)
      • -the radial head slips out from under the annular ligament.
      • -Generally caused by sudden traction of the forearm that extends and pronates the elbow (like the motion of pulling a child off the ground by his/her wrist).
      • -Most common in children aging 1 - 3years.girls > boys Recurrence : 20%.
      • iv. No associated swelling, ecchymosis, or neurovascular deficit.
      • Radiography - Normal findings.
    •  
    • Epicondylitis (Tennis Elbow)
      • an inflammatory process that involves the radiohumeral joint or lateral epicondyle of the humerus.
      • It is a common exercise-related syndrome, is thought to be repetitive pronation and supination of the forearm.
      • Clinical Features:
      • - gradual onset.
      • - dull pain over the lateral aspect of the elbow, increased by grasping or twisting motions.
      • - Tenderness over the lateral epicondyle.
      • To test for tennis elbow: the elbow is extended, the forearm pronated, and the wrist fully dorsiflexed.
      • treatment: protection, (RICE), and medication.