Elbow and forearm fractures


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Elbow fractures explained in a simplified, manner.

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Elbow and forearm fractures

  2. 2. Elbow joint Anatomy
  3. 3. Fractures of the distal humerus In adults they are associated with high-energy injuries. In children - falls with an outstretched arm The AO-ASIF Group have defined three types of distal humeral fracture: Type A – an extra-articular supracondylar fracture; Type B – an intra-articular unicondylar fracture (one condyle sheared off); Type C – bicondylar fractures with varying degrees of comminution.
  4. 4. Supracondylar fractures type A rare in adults. Usually they are displaced and unstable In high-energy injuries there may be comminution of the distal humerus
  5. 5. Treatment  Open reduction and internal fixation.  Mostly plates and screws are used  Closed reduction is unlikely to be stable  K-wire fixation is not strong enough to permit early mobilization.
  6. 6. Types B and C intra articular fractures high-energy FRACTURES AND JOINT INJURIES injuries with soft-tissue damage. A severe blow on the point of the elbow drives the olecranon process upwards, splitting the condyles apart. Swelling is considerable.  The patient should be checked for i. Pulselessness ii. Pallor iii. Pain iv.Paresthesia v. Paralysis
  7. 7. X-ray  T- or Y shaped break, or else there may be (comminution).
  8. 8. Treatment type Undisplaced fractures Joint damage- prolonged immobilization will certainly result in a stiff elbow. Early movement is a prime objective. Treated by applying a posterior slab with the elbow flexed almost 90 degrees; movements are commenced after 2 weeks.
  9. 9. Reduction of a supracondylar fracture
  10. 10. Txt Displaced type B and C  ORIF  K wire can be used  unicondylar fracture without comminution can then be fixed with screws; if the fragment is large, a contoured plate is added to prevent re-displacement.  Plates with locking screws  Postoperatively the elbow is held at 90 degrees with the arm supported in a sling. Movement is encouraged but should never be forced.  Fracture healing usually occurs by 12 weeks.  patient often does not regain full extension
  11. 11. Alternative treatments  Elbow replacement  The ‘bag of bones’ technique.  The arm is held in a collar and cuff or, better, a hinged brace, with the elbow flexed above a right angle; active movements are encouraged as soon as the patient is willing. The fracture usually unites within 6–8 weeks, but exercises are continued far longer. A useful range of movement (45–90 degrees) is often obtained.  Skeletal traction the patient remains in bed with the humerus held vertical, and elbow movements are encouraged.
  12. 12. Complications of supracondylar fractures  Vascular injury  Nerve injury median nerve  Volkmann’s ischemic contracture  Malunion leading to gunstock deformity  Myositis ossificans  Stiffness
  13. 13. FRACTURED CAPITULUM  rare articular fracture  Mainly occurs in adults  elbow is tender and flexion is grossly restricted  Mechanism of injury The patient falls on the hand, usually with the elbow straight. The anterior part of the capitulum is sheared off and displaced proximally
  14. 14. X-rays Bryan and Morrey classify these as: i. Type I Complete fracture ii. Type II Cartilaginous shell iii. Type III Comminuted fracture.
  15. 15. Can You See The Capitulum
  16. 16. Treatment  Undisplaced fractures can be treated by simple splintage for 2 weeks.  Displaced fractures should be reduced and held.  Closed reduction is feasible, but prolonged immobilization may result in a stiff elbow.  ORIF is therefore preferred.  Using headless bone screws  Movements are commenced as soon as discomfort permits
  17. 17. Fractured head of the Radius Common in adults A fall on the outstretched hand with the elbow extended and the forearm pronated Impaction of the radial head against the capitulum causes the radial head to split or brake Clinical features - tenderness on pressure over the radial head and pain on pronation and supination
  18. 18. X-rays  Three types of fracture are identified and classified by Mason as: i. Type I An undisplaced vertical split in the radial head ii. Type II A displaced single fragment of the head iii. Type III The head broken into several fragments (comminuted).
  19. 19. Treatment  An undisplaced split (Type I)  Aspirating the haematoma and injecting local anaesthetic.  The arm is held in a collar and cuff for 3 weeks; active flexion, extension and rotation are encouraged.  The prognosis for this injury is very good  A single large fragment (Type II)  reduced and held with one or two small headless screws.
  20. 20. Treatment  A comminuted fracture (Type III).  Always assess for an associated soft tissue injury: i. Rupture of the medial collateral ligament ii. Rupture of the interosseous membrane iii. Combined fractures of the radial head and coronoid process plus dislocation of the elbow ‘the terrible triad’.  If any of these is present, excision of the radial head is contra- indicated; this may lead to intractable instability of the elbow or forearm.  The head must be reconstructed with small headless screws or replaced with a metal spacer.  A medial collateral rupture, if unstable after replacing or fixing the radial head, should be repaired.
  21. 21. Complications  Joint stiffness both the elbow and the radioulnar joints.  Delayed union  Stiffness  Myositis ossificans  Recurrent instability of the elbow joint
  22. 22. Fractures of the olecranon  Two broad types of injury are seen: i. Comminuted fracture which is due to a direct blow or a fall on the elbow ii. A transverse break, due to traction when the patient falls onto the hand while the triceps muscle is contracted.  These two types can be further sub-classified into i. Displaced fractures ii. Undisplaced fractures.  Subluxation or dislocation of the ulno-humeral joint in severe injuries  The fracture always enters the elbow joint and therefore damages the articular cartilage.
  23. 23. Clinical features  A graze or bruise over the elbow suggests a comminuted fracture; the triceps is intact and the elbow can be extended against gravity.  With a transverse fracture there may be a palpable gap and the patient is unable to extend the elbow against resistance.
  24. 24. Treatment  A comminuted fracture with the triceps intact should be rested in a sling for a week; then encouraged to start active movements.  An undisplaced transverse fracture that does not separate when the elbow is in flexion can be treated closed.  The elbow is immobilized by a cast in about 60 degrees of flexion for 2–3 weeks and then exercises are begun.  Displaced transverse fracture ORIF is done. The fracture is reduced and held by tension band wiring.  Oblique fractures may need a lag screw, neutralized by a tension band system or plate.
  25. 25. Treatment  Displaced comminuted fractures need a plate and often bone graft.  Following operation, early mobilization should be encouraged.
  26. 26. Main Complications Stiffness Non-union due to inadequate reduction and fixation. Ulnar nerve symptoms can develop. Osteoarthritis
  27. 27. Radius and Ulnar bones
  28. 28. Fractures of the radius and the ulna Common both in children and adults Mechanism of injury Twisting forces produces a spiral fracture with the bones broken at different levels. An angulating force causes a transverse fracture of both bones at the same level. A direct blow causes a transverse fracture of just one bone, usually the ulna. Additional rotation deformity may be produced by the pull of muscles attached to the radius
  29. 29. Clinical features Obvious fractures due to deformity Check for the five P’s i. Pulselessness ii. Pallor iii. Pain iv.Paresthesia v. Paralysis
  30. 30. X-ray Both bones are broken In children, the fracture is often incomplete (greenstick) and only angulated. In adults, displacement may occur in any direction – shift, overlap, tilt or twist. In low-energy injuries, the fracture tends to be transverse or oblique; in high-energy injuries it is comminuted or segmental
  31. 31. X-ray images of the forearm
  32. 32. Treatment in children Closed treatment because the tough periosteum tends to guide and then control the reduction. The fragments are held in a full-length cast, from axilla to metacarpal shafts (to control rotation). For 6-8weeks. The cast is applied with the elbow at 90 degrees. If the fracture is proximal to pronator teres, the forearm is supinated; if it is distal to pronator teres, then the forearm is held in neutral.
  33. 33. Treatment in children continued If the conservative method fails ORIF is done Fixation with intramedullary rods is preferred, avoid injury to the growth plates. Alternatively, a plate or K-wire fixation can be used. Childhood fractures usually remodel well, but not if there is any rotational deformity or an angular deformity
  34. 34. Treatment in adults  Open reduction and internal fixation The fragments are held by inter fragmentary compression with plates and screws. Bone grafting is advisable if there is comminution. The deep fascia is left open to prevent compartment syndrome, only the skin is sutured. External fixation if it is a compound fracture
  35. 35. Plate and screws
  36. 36. Adult treatment After the operation the arm is kept elevated until the swelling subsides, and during this period active exercises of the hand are encouraged. If the fracture is stable Early ROM exercises are commenced but lifting and sports are avoided. It takes 8–12 weeks for the bones to unite. With comminuted fractures or unreliable patients, immobilization in plaster is safer.
  37. 37. Complications Early complications Nerve injuries Vascular injury Compartment syndrome Late complications Delayed union and nonunion Malunion and cross union Complications of plate removal
  38. 38. Isolated fracture of the forearm Uncommon Caused by direct trauma E.g. when protecting the face Clinical features X-ray showing fractures, ulnar fracture difficult to see Swelling Deformity Dislocations on the distal and proximal joints
  39. 39. Treatment Isolated fracture of the ulna Undisplaced fracture Elbow flexed full arm cast or forearm brace. 8 weeks before full activity can be resumed. Displaced fractures ORIF to prevent rotational elements Advantage allow earlier activity and avoids the risk of displacement or non-union.
  40. 40. Treatment Isolated fracture of the radius Radius fractures are prone to rotary displacement; To achieve reduction in children the forearm needs to be i. supinated for upper third fractures, ii. neutral for middle third fractures iii. pronated for lower third fractures. If the reduction fails; then internal fixation with a compression plate and screws in adults, and preferably intramedullary rods in children.
  41. 41. Isolated fractures of the forearm
  42. 42. Monteggia Fracture Fracture of the shaft of the ulna associated with dislocation of the proximal radio-ulnar joint and the radiocapitellar joint. In children, the ulnar injury may be an incomplete fracture (greenstick or plastic deformation of the shaft)
  43. 43. Mechanism of injury Usually the cause is a fall on the hand; if at the moment of impact the body is twisting, its momentum may forcibly pronate the forearm. The radial head usually dislocates forwards and the upper third of the ulna fractures and bows forwards. Sometimes the causal force is hyperextension
  44. 44. Clinical features ulnar deformity is usually obvious the dislocated head of radius is masked by swelling. A useful clue is pain and tenderness on the lateral side of the elbow.  The wrist and hand should be examined for signs of injury to the radial nerve.
  45. 45. X-RAYS The head of the radius is dislocated forwards, and there is a fracture of the upper third of the ulna with forward bowing. Backward or lateral bowing of the ulna is likely to be associated with, respectively, Posterior or lateral displacement of the radial head. Trans-olecranon fractures, also, are often associated with radial head dislocation.
  46. 46. Monteggia Fracture X-ray
  47. 47. Treatment  Aim is to restore the length of the fractured ulna  The ulnar fracture must be accurately reduced, with the bone restored to full length, and then fixed with a plate and screws.  The radial head usually reduces once the ulna has been fixed.  Stability must be tested through a full ROM.  If the elbow is completely stable, then flexion–extension and rotation can be started after surgery.  If there is doubt, then the arm should be immobilized in plaster with the elbow flexed for 6 weeks
  49. 49. Ulnar Fracture Hume fracture - a fracture of the olecranon with an associated anterior dislocation of the radial head
  50. 50. GALEAZZI FRACTURE-DISLOCATION OF THE RADIUS Fractured radius with dislocation of the distal radioulnar joint More common than the Monteggia fracture Mechanism of injury Fall on an outstretched hand; probably with a rotation force. The radius fractures in its lower third and the inferior radio-ulnar joint subluxates or dislocates.
  51. 51. Clinical features Prominence or tenderness over the lower end of the ulna. It may be possible to demonstrate the instability of the radio-ulnar joint by rotating the wrist. Test for an ulnar nerve lesion X-ray A transverse or short oblique fracture is seen in the lower third of the radius, with angulation or overlap. The distal radio-ulnar joint is subluxated or dislocated.
  52. 52. Treatment restore the length of the fractured bone Conservative method is usually successful in children In adults ORIF and compression screws of the radius X-ray to verify that the distal radio-ulnar joint is reduced
  53. 53. Reduced Galeazzi Fracture
  54. 54. Complications Malunion because the distal fragment has no longitudinal support Cross union Compartment syndrome
  55. 55. Radius fracture Essex-Lopresti fracture - a fracture of the radial head with concomitant dislocation of the distal radio-ulnar joint with disruption of the interosseous membrane.
  56. 56. Physiotherapy treatment  The physiotherapist carries out an assessment of the patient and then formulates a plan of treatment. Aims of physiotherapy treatment  To reduce any swelling.  To regain full range of joint movement.  To regain full muscle power.  To re-educate full function.  Maintain Soft Tissue and Joint Mobility  Maintain Integrity and Function of Related Areas
  57. 57. Physiotherapy management  soft tissue massage  joint mobilization  electrotherapy (e.g. ultrasound)  taping or bracing  ice or heat treatment  the use of a protective gear like splints  exercises to improve strength, flexibility and balance  hydrotherapy  Patient education  activity modification eg ADL’s  a graduated return to activity plan
  58. 58. Physiotherapy treatment Reduce Effects of Inflammation or Synovial Effusion and Protect the Area Immobilization in a sling provides rest to the part, weigh with complete immobilization Frequent periods of controlled movement within a pain-free range should be performed.
  59. 59. Salter Harris Classification
  60. 60. References  Apley’s System of Orthopedics and Fractures