Fractures of the distal humerus
In adults they are associated with high-energy
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
Type B – an intra-articular unicondylar fracture
(one condyle sheared off);
Type C – bicondylar fractures with varying
degrees of comminution.
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
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
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
T- or Y shaped break, or else there may be (comminution).
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.
Txt Displaced type B and C
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
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
the patient remains in bed with the humerus held
vertical, and elbow movements are encouraged.
Complications of supracondylar fractures
Nerve injury median nerve
Volkmann’s ischemic contracture
Malunion leading to gunstock deformity
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
The anterior part of the capitulum is sheared off and
Bryan and Morrey classify these as:
i. Type I Complete fracture
ii. Type II Cartilaginous shell
iii. Type III Comminuted fracture.
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
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
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).
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.
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
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.
Joint stiffness both the elbow and the radioulnar joints.
Recurrent instability of the elbow joint
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
The fracture always enters the elbow joint and therefore
damages the articular cartilage.
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
A comminuted fracture with the triceps intact should be
rested in a sling for a week; then encouraged to start
An undisplaced transverse fracture that does not
separate when the elbow is in flexion can be treated
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.
Displaced comminuted fractures need a plate and often bone
Following operation, early mobilization should be encouraged.
Non-union due to inadequate reduction and
Ulnar nerve symptoms can develop.
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
Obvious fractures due to deformity
Check for the five P’s
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
Treatment in children
Closed treatment because the tough
periosteum tends to guide and then control the
The fragments are held in a full-length cast, from
axilla to metacarpal shafts (to control rotation).
The cast is applied with the elbow at 90
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.
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
Childhood fractures usually remodel well, but
not if there is any rotational deformity or an
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
The deep fascia is left open to prevent
compartment syndrome, only the skin is sutured.
External fixation if it is a compound fracture
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.
Delayed union and nonunion
Malunion and cross union
Complications of plate removal
Isolated fracture of the forearm
Caused by direct trauma
E.g. when protecting the face
X-ray showing fractures, ulnar fracture difficult
Dislocations on the distal and proximal joints
Isolated fracture of the ulna
Elbow flexed full arm cast or forearm brace.
8 weeks before full activity can be resumed.
ORIF to prevent rotational elements
Advantage allow earlier activity and avoids
the risk of displacement or non-union.
Isolated fracture of the radius
Radius fractures are prone to rotary
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.
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)
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
Sometimes the causal force is hyperextension
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.
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
Trans-olecranon fractures, also, are often
associated with radial head dislocation.
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
The radial head usually reduces once the ulna has been
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
Hume fracture - a fracture of the
olecranon with an associated
anterior dislocation of the radial
OF THE RADIUS
Fractured radius with dislocation of the distal
More common than the Monteggia fracture
Mechanism of injury
Fall on an outstretched hand; probably with a
The radius fractures in its lower third and the
inferior radio-ulnar joint subluxates or
Prominence or tenderness over the lower end of the
It may be possible to demonstrate the instability of
the radio-ulnar joint by rotating the wrist.
Test for an ulnar nerve lesion
A transverse or short oblique fracture is seen in
the lower third of the radius, with angulation or
The distal radio-ulnar joint is subluxated or
restore the length of the fractured bone
Conservative method is usually successful in
In adults ORIF and compression screws of the
X-ray to verify that the distal radio-ulnar joint is
Malunion because the distal fragment has no
Essex-Lopresti fracture - a fracture of the
radial head with concomitant dislocation
of the distal radio-ulnar joint with disruption
of the interosseous membrane.
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
soft tissue massage
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
activity modification eg ADL’s
a graduated return to activity plan
Reduce Effects of Inflammation or
Synovial Effusion and Protect the Area
Immobilization in a sling provides rest to
the part, weigh with complete
Frequent periods of controlled movement
within a pain-free range should be