Distal humeral fracturesAo – asif group classification Type A – an extra-articular supracondylarfracture; Type B – an intra-articular unicondylar fracture(one condyle sheared off); Type C – bicondylar fractures with varyingdegrees ofcomminution.
Capitulum fracturesBryan and Morey classificationType I: Hahn-Steinthal fragment. Large osseouscomponent of capitellum, sometimes withtrochlear involvementType II: Kocher-Lorenz fragment. Articularcartilage with minimal subchondral boneattached: “uncapping of the condyle”Type III: Markedly comminuted
Head of radius fracturesMason classification Type I An undisplaced vertical split in the radialhead Type II A displaced single fragment of the head Type III The head broken into severalfragments (comminuted).
Radial neck fractures A fall on the outstretched hand forces theelbow into valgus and pushes the radial headagainst the capitulum. In children the bone fractures through the neckof the radius; in adults the injury is more likelyto fracture the radial head.
Olecranon process fracturesTwo broad types of injury are seen:(1) a comminuted fracture which is due to a direct blowor a fall on the elbow(2) a transverse break, due to traction when the patientfalls onto the hand while the triceps muscle iscontracted.These two types can be further sub-classified into(a) Displaced(b) Undisplaced fractures.More severe injuries may be associated alsowith subluxation or dislocation of the ulno-humeraljoint.
Olecranon process fracturesMorrey Classification Type I: Undisplaced, stable fractures Type II: Displaced, stable Type III: Displaced, unstable fractures
Coronoid process fracturesRegan and Morrey classificationType I: Fracture avulsion just the tip of thecoronoidType II: Those that involve less than 50% ofcoronoid either as single fracture or multiplefragmentsType III: Those involve >50% of coronoidSubdivided into those(A)without elbow dislocation(B)with elbow dislocation
Treatment Surgical treatment is given as appropriate Plates and screws for comminuted fractures Headless or lag screws for uncomminutedfractures Collar and cuff for splinting or other splints innon surgical intervention.
Physiotherapy mxProblems Stiffness of the elbow Loss of extension and flexion and sometimespronation and supination Pain Myositis ossificans Vascular insufficiency Nerve damage (ulnar and median nerve) Mul union
Physio mxProblems Delayed union Non union Elbow instability Muscle spasm Muscle weakness Muscle atrophy Joint deformity Bone infection (osteomyelitis) Osteoporosis loss of bone density as a result of reducedfunctionality Thrombus formation
Physio mx Ultrasound to loosen adhesions/ myositisossificans Massage (hacking) and muscle stretch torealese contractures Range of motion exercizes to increaseextension, flexion, supination and pronation. Tens/ift for pain medication and muscle spasm.
Physio mx Circulatory exercizes for vascular insufficiency Nerve glides for nerve damage if neuropraxic Nerve stretching Immobilisation in cast in cases of mal union,delayed union and non union then refere for reassesment. Immobilising in armsling for elbow instability.Untill healing takes place.
Muscle strengthening exercizes for muscleweakness, muscle atrophy and immobilityosteoporosis. Order for a check x-ray if there is jointdeformity for appropriate progression oftherapy. with chronic uhealing wounds discharging pussuspect osteomyelitis, and recommend biopsyfor microbiology examination. tubi grip will be appropriate for dvt (paget vonschruetter disease).
DislocationsGeneral• The most common type of dislocation inchildren and the second most common type inadults, second only to shoulder dislocation• Young adults between the ages of 25–30 yearsare most affected and sports activitiesaccount for almost 50% of these injuries• Mechanism: Fall on the outstretched hand
Clinical• Dislocation can be anterior or posterior withposterior being the most common, occurring98% of the time.• Associated injuries include fracture of the radialhead, injury to the brachial artery and mediannerve
Isolated dislocation of radialhead A true isolated dislocation of the radial head isvery rare; if it is seen, search carefully for anassociated fracture of the ulna (the Monteggiafracture). In a child, the ulnar fracture may be difficult todetect if it is incomplete, either green-stick orplastic deformation of the shaft; it is very important to identify these incompletefractures because even a minor deformity, if it isallowed to persist, may prevent full reduction oftheradial head dislocation.
Symptoms• Inability to bend the elbow following a fall onthe outstretched hand• Pain in the shoulder and wrist• On physical exam: The most important part ofthe exam is the neurovascular evaluation of the radial artery, and median, ulnar and radialnerves
Imaging• Plain AP and lateral radiographs• CT and MRI scans are seldom necessary
Treatment• Reduce dislocation as soon as possible afterinjury• Splint for 10 days• Initiate ROM exercises, NSAIDs
Complications• Loss of ROM of elbow especially extension• Ectopic bone formation• Neurovascular injury• Arthritis of the elbow
References Apley orthopaedic textbook Upper limb fractures Physical medicine and rahabilitation