Melbourne Arm Clinic GP education Wrist and elbow injuries Orthopaedic Upper Limb Surgeons

1. Wrist and elbow
injuries

2. Wrist Injuries and their
sequlae
• TYPICAL
• “ Had a fall while playing footy”
• “ Fell off my Mountain Bike”
• “motor vehicle accident”

3. • ATYPICAL
• “ I work as a carpenter and I got up this morning and it was
really sore”
• “ I thought I sprained it when I was arm wrestling with my
brother”
• “ got up this morning and its been really aching and you can
see the swelling”

4. • On Further questioning, what you may hear is:
• “ ah yes, I think I had an injury when I was a kid”
• “now that you ask, I had landed on this same wrist 2 months
ago, it was sore for a couple of days and I dismissed it as a
sprain”

5. • On examination:
• You may localize the pain as radial sided or ulnar sided
• If its Radial sided:
• SCAPHOID fracture!
• Scapholunate instability
• Radial Styloid fracture
• Trapezium fracture
• Base of Thumb OA
• Colles fracture
• Dequervains tenosynovitis

6. • If its Ulnar Sided/ or central dorsal:
• Lunate injuries : a dislocation?
• Keinbock s disease of the Lunate
• Ulnar sided impaction on carpus due to old malunited
shortened distal radius fractures
• TFCC injuries
• DRUJ injuries, acute or chronic
• ECU injuries or snapping
• Uncommonly cysts and tumours

7. THE SCAPHOID!

9. • I always prefer X rays , which are a baseline investigative tool
for all scaphoid fractures.
• Scaphoid views must be asked for specifically
• Almost all X rays must be complimented with a CT
• MRI
• 1. for children
• 2. Where AVN is suspected, for proximal pole fractures
• 3. Where there may be a soft tissue component in addition to
the scaphoid fracture, such as a perilunate injury.

12. • Even for “undisplaced” fractures, what interests me is the
amount of a “Humpback deformity”

13. • Aim of treatment for Scaphoid fractures:
• PRIMARY:
• Achieve solid union
• SECONDARY
• Shortest time to healing with least disruption to the patient, in
terms of use of the arm and wrist stiffness
• Prevention of the natural progression of this condition left
untreated which is known as a SNAC wrist which is essentially
arthritis

14. TREATMENT
• Cast for undisplaced scaphoids is acceptable!
• I define Undisplaced scaphoids as one where its hard to pick
up the fracture on a plain x ray , however its seen on a ct.
• PROS of cast:
• Easy
• Non expensive
• Non invasive
• Works well for undisplaced fractures
• CONS:
• Stiffness
• Inconvenient
• May not unite

16. CAST DURATION
• Distal pole: 6 weeks
• Waist: 8 weeks
• Proximal Pole :12 weeks

17. OPERATIVE

19. • TO SUMMARISE: THE FIVE QUESTIONS THAT MUST BE ASKED
• Is there an associated distal radius / other carpal bone injury?
• Is there a Proximal pole fracture?
• Is there a Displaced waist fracture?
• Is there a Humpback deformity on a Ct?
• Is it chronic and is it really a non union now?
• Answer of yes to any, will benefit from surgery!
•

20. RESULTS

21. AVN
• Seen in Proximal pole fractures and most likely, all patients
with a proximal pole fracture need fixation which increases
the chances of union and decreases the chance of AVN

23. When to refer?
• Any chronic scaphoid fracture
• A scaphoid fracture picked up late, even if undisplaced
• A displaced scaphoid fracture: any scaphoid fracture that is
clearly visible on an x ray is considered displaced
• Combination injuries
• A sequelae of a scaphoid fracture known as a SNAC wrist, this
is a non union of a scaphoid with early arthritis . Xrays and Ct
will suffice.

24. A SCAPHOLUNATE INJURY

28. • When the initial x rays are normal, the patient has a swollen
wrist with tenderness on the dorsum and over the scaphoid,
an MRI is a good adjunct , as it shows the scapholunate
ligament disruption very clearly.
• Depending on the amount of disruption, surgery is often
required
• These are severe injuries which can potentially impact the use
of the arm, with respect to the patients occupation, so it is
important to refer these patients early!

31. KEINBOCK S DISEASE
• This is yet another condition that requires early detection and
treatment. This is a disease generally seen in the young
patient .
• We don’t know the cause.
• The disease is progressive
• What Medical science can offer are “ salvage surgeries” not
really a cure.

32. • Postulated that there is an increase in Intraosseus pressure,
the cause of the increased pressure is unknown
• Some blame is due to an aberration in the native blood supply
to the lunate

34. • DIAGNOSIS:
• Generally males aged 20-40
• Pain over the dorsocentral aspect of the wrist
• Pain and weakness whilst gripping
• Swelling at the back of the wrist with tenderness
• X rays and MRI

37. Left untreated!

38. • If Picked up early:
• Can offer a radial or ulnar shortening , with excellent results
• If Picked up late:
• Can offer limited or full fusions of the wrist, which are good
from a pain perspective but at the expense of movement

39. New generation: pyrocarbon
lunate replacements

40. ELBOW
• ELBOW DISLOCATIONS AND THE ASSOCIATED CONDITIONS:
• 1. PURELY SOFT TISSUE INJURIES
• 2. TERRIBLE TRIADS
• 3. RADIAL HEAD FRACTURES

41. Elbow Dislocations
• I prefer to see every dislocation.
• A lot of the Emergency departments don’t record if the Elbow
is stable or not at the time of enlocation and they are sent off
as “ simple “ elbow dislocations.
• A lot of injuries are missed in the process

42. • Example:

44. • EARLY diagnosis and appropriate investigations by means of x
rays and Ct , rarely MRI are important for treatment
• Treatment involves ligament reconstruction or repair, and
fixation of bony fragments with an aim to start early physical
therapy, and minimize stiffness

45. Radial head fractures
• Very common
• Generally after a fall on an outstretched hand
• X rays and sometimes CT are required.

46. • When to refer?
• 1. Displaced fractures
• 2. in conjunction with other injuries such as fractures around
the elbow or soft tissue injuries
• 3. communited fractures
• A lot of the population have simple undisplaced fractures that
can be treated in a sling for 10 days and mobilize as soon as
the swelling and pain settle , which is generally around the 5
days mark.
• These have predictable and good results

47. TERRIBLE TRIAD INJURY
• Elbow dislocation
• Coronoid Fracture
• Radial head fracture

48. • This needs fixation always and a dedicated physiotherapy
protocol that can be found on our Melbourne Arm Clinic
website, in order to get the best outcome from a “ terrible”
injury.