Tans femoral Amputee : Prosthetics Knee Joints.pptx
Fractures around elbow lateral condyle and intercondylar fractures
1. Fractures around the elbow
(Lateral condyle fractures and
intercondylar fractures)
Dr Siddhartha Sinha, Senior Resident
Department of Orthopaedics
Lady Hardinge Medical College, New Delhi
2. Anatomy
• Hinge joint with articulation between
• Lower end of the humerus with ulna
(humero-ulnar joint)
• Head of the radius (humero-radial joint).
• Distal humerus is enlarged to form
• Trochlea medially, Medial to the trochlea is
a prominent process - medial epicondyle
• Capitulum laterally, :Lateral to the
capitulum is the lateral epicondyle.
3.
4.
5. Three bony points relationship
• 3 Points
• Medial epicondyle,
• Lateral epicondyle
• Tip of the olecranon
• Extension = straight line
• Flexion = isosceles triangle
• Deranged in
• Elbow dislocation
• Lateral condyle/ Medial epiondyle #
• Intercondylar # elbow (increased base)
• Maintained in
• Supracondylar fractures
• 4th point: Head of radius (palpate in semi
flexed elbow in pronation and supination)
6. Carrying Angle
• Angle formed between
arm and forearm on full
extension and supination
• 11° in males
• 14° in females
• Evolution so that upper
limb can clear body
when carrying loads.
8. Paediatric elbow
• Upper extremity fractures 65-75% of all paeditric traumas due to
tendency of children to fall on oustretched hand.
• Distal humerus # -86% of all elbow # in children
• Supracondylar # - Most common
• Lateral condyle #
• Medial epicondyle #
• Physis may be confused for a fracture in children
• Good clinical examination
• Radiographs of bilateral elbow for comparison
9. Ossification around elbow
• A) CRMTOL:
Mnemonic for the appearance of the
ossification centers around the
elbow
• Capitellum: 6 months to 2 years;
includes the lateral crista of the
trochlea
• Radial head: 4 years
• Medial epicondyle: 6 to 7 years
• Trochlea: 8 years
• Olecranon: 8 to 10 years; often
multiple centers, which ultimately
fuse
• Lateral epicondyle: 12 years
• B) Age of fusion of ossification centers
10. Radiography of paediatric elbow
• Standard AP view
• Baumanns angle: the
angulation of the
physeal line between
the lateral condyle
and the distal
humeral metaphysis.
• Humeral- ulnar angle
–true carrying angle
• Metaphyseal –
diaphyseal angle
• Special view-
• Jones view
• Internal and external
rotation views
11. • Lateral view
• Tear drop
• Shaft condylar angle
• Anterior Humeral line
• Coronoid line
• Lateral Humerocapitellar
angle
• Fat pad signs
• Olecranon (posterior)
• Coronoid (anterior)
• Supinator
12. Lateral condyle Fractures
• 17% of all distal humeral
fractures in children
• Peak age 6yrs
• Fracture of necessity- must be
fixed as it often leads to non
union
• Often result in less satisfactory
outcomes than supracondylar
fractures because:
• Diagnosis less obvious and may
be missed in subtle cases.
• Loss of motion is more severe
due to intra-articular nature.
• The incidence of growth
disturbance is higher
13. Anatomy of lateral condyle fractures
• Anatomy
• The ossification center of the lateral condyle extends to the lateral crista of
the trochlea.
• Typically accompanied by a soft tissue disruption
• origins of the extensor carpi radialis longus and the brachioradialis muscles
• remain attached to the free distal fragment, accounting for initial and late displacement
of the fracture.
• Disruption of the lateral crista of the trochlea (Milch type II fractures) results
in posterolateral subluxation of the proximal radius and ulna with consequent
cubitus valgus
14. Mechanism of injury
• “Pull-off” theory: Avulsion injury occurs by the
common extensor origin owing to a varus stress
exerted on the extended elbow.
• “Push-off” theory: A fall onto an extended upper
extremity results in axial load transmitted through
the forearm, causing the radial head to impinge on
the lateral condyle.
15. Clinical evaluation
• Pain
• Swelling
• Tenderness to
palpation
• Crepitus
• Painful range of
motion
• Pain on resisted wrist
extension
16. Radiographic Evaluation
• AP, lateral, and oblique views of the elbow
• Varus stress views may accentuate
displacement of the fracture.
• Radiological D/D:
• Lateral condyle fracture
• Fracture of the entire distal humeral physis
• Arthrogram: assess relationship of lateral condyle
to proximal radius and distinguish from complete
distal humeral physeal fracture
• MRI –
• Appreciate the direction of the fracture line
and the pattern of fracture.
• Not routinely done
17. Classifiation of lateral condyle fractures
• Milch
• Type I
• The fracture line courses lateral to the trochlea and
into the capitellar–trochlear groove.
• Salter-Harris type IV fracture: the elbow is stable
because the trochlea is intact
• Less common.
• Type II:
• The fracture line extends into the apex of the
trochlea.
• Salter-Harris type II fracture
• Elbow is unstable because the trochlea is disrupted;
• More common
18. Classification
• Stages of displacement (Jakob et al)
• Stage 1: Fracture relatively non displaced,
articular surface intact, trochlea intact, no
lateral shift of olecranon
• Stage 2: Fracture extends completely through
the articular surface, proximal fragment
displaced, lateral shift of olecranon
• Stage 3 condylar fragment rotated, displaced
laterally and proximally, translocation of
olecranon and radial head.
19. Treatment
• Non operative
• Non-displaced or minimally displaced fractures
(Jakob stage I; <2 mm)
• Simple immobilization in a posterior splint or long
arm cast with the forearm in neutral position and the
elbow flexed to 90 degrees.
• This is maintained for 3 to 6 weeks until there is
healing of the fracture, after which range-of-motion
exercises are instituted.
20. • Closed reduction
• Varus force as well as supination and extension may be attempted
• Jakob type II fractures.
• If articular reduction is achieved hold with percutaneous wires in order to prevent
displacement.
• An arthrogram can be performed to ensure a reduction was achieved.
• Closed reduction is often difficult because of medial soft tissue swelling
• Not routinely done
21. • Open Reduction
• Stages II and III fractures.
• Open reduction using lateral approach
and fixation with K wires
• Postoperative immobilization -long arm
casting/slab with the forearm in neutral
rotation and the elbow flexed to 90
degrees for 3 to 4 weeks
• After 3-4 weeks pins and the cast may
be discontinued and active range-of-
motion exercises instituted.
• If treatment is delayed (>3 to 6
weeks)
• closed treatment regardless of
displacement,
• High incidence of osteonecrosis of the
trochlea and significant joint stiffness
from extensive dissection with late open
reduction
22. Complications of lateral condyle fractures
1. Nonunion:
• Wide displacement of fragment
and soft tissue interposition
• “ Pull of extensors” attached to
fragment
• Treatment: Early cases- ORIF,
Late cases- Manage
consequences like deformity
and instability
2. Angular deformity:
• Cubitus valgus may result from
overgrowth of the medial
condyle.
• Treatment of cubitus valgus:
• Mild – no t/e
• Moderate to severe
deformity- supracondylar
osetotomy
23. 3. Late ulnar nerve palsy (tardy Ulnar nerve palsy)
due to cubitus valgus (late complicaition)
1. C/o tingling and numbness in the distribution of
ulnar nerve
2. T/t : Anterior transposition of ulnar nerve in front
of the medial epicondyle to prevent friction
4. Osteonecrosis:
1. After open reduction and internal fixation, with
extensive soft tissue dissection
5. Ulnar neuropathy:
1. Early, related to trauma
2. More commonly, late, related to the
development of angular deformities or scarring.
3. Symptoms may be addressed with ulnar nerve
transposition.
24. Intercondylar fractures
• 2nd common distal humerus
fractures in adults (1st=
extraarticular # distal humerus)
• T or Y shape of fracture line
• Comminution common
25. Mechanism of injury
• Fall on elbow driving olecranon into distal humerus
splitting the two condyles due to the action of the
flexors (medially ) and extensors (laterally) and
rotation around the horizontal axis
27. Treatment
• Nonoperative Management
• Nondisplaced fractures,
• Elderly patients with displaced fractures
• Severe osteopenia and comminution
• Patients with significant comorbid conditions
precluding operative management.
• Cast immobilization:
• Not preferred due to inadequate fracture reduction
and prolonged immobilization.
• “Bag of bones”:
• The arm is placed in a collar and cuff with as much
flexion as possible after initial reduction is attempted;
gravity traction helps effect reduction. The idea is to
obtain a painless “pseudarthrosis,” which allows for
motion.
28. Operative management
• Preferred treatment
• Aim to restore joint surfaces,
columns and tie arch Open reduction
and internal fixation
• Interfragmentary screws
• Dual plate fixation:
• one plate medially and another plate
placed posterolaterally
• 90 degrees from the medial plate or two
plates on either column
• 180 degrees from one another
• Total elbow arthroplasty (cemented,
semiconstrained):
• This may be considered in markedly
comminuted fractures and with fractures
in osteoporotic bone.
• Postoperative care: Early range of
motion of the elbow is essential
unless fixation is tenuous
29. Complications
• Posttraumatic arthritis:
• articular injury at time of trauma
• failure to restore articular congruity.
• Failure of fixation:
• Loss of motion (extension):
• With prolonged periods of immobilization.
• Range of motion exercises should be instituted as soon as the patient is able to tolerate therapy,
• Heterotopic bone
• Neurologic injury (up to 15%): The ulnar nerve is most commonly injured during surgical
• exposure.
• Nonunion of osteotomy: 5% to 15%
• Infection