This document discusses fractures of the elbow and forearm. It describes the anatomy of the elbow joint and various types of fractures that can occur in the distal humerus, radial head, coronoid process, and olecranon. Treatment options for different fracture patterns include closed reduction, open reduction and internal fixation using plates, screws and tension band wiring. Complications like stiffness, non-union and nerve injuries are also discussed. Physiotherapy management aims to regain range of motion, muscle strength, and function.

1. ELBOW AND FOREARM
FRACTURES FRACTURES
PRESENTED BY
MWADZIWANA LOUIS LAW

2. Elbow joint Anatomy

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. 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

6. 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.

7. 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

8. X-ray
 T- or Y shaped break, or else there may be (comminution).

9. 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.

11. Reduction of a supracondylar fracture

12. 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

14. 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.

15. Complications of supracondylar fractures
 Vascular injury
 Nerve injury median nerve
 Volkmann’s ischemic contracture
 Malunion leading to gunstock deformity
 Myositis ossificans
 Stiffness

18. 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

19. X-rays
Bryan and Morrey classify these as:
i. Type I Complete fracture
ii. Type II Cartilaginous shell
iii. Type III Comminuted fracture.

20. Can You See The Capitulum

21. 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

22. 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

23. 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).

24. 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.

25. 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.

26. Complications
 Joint stiffness both the elbow and the radioulnar joints.
 Delayed union
 Stiffness
 Myositis ossificans
 Recurrent instability of the elbow joint

27. 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.

29. 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.

30. 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.

31. Treatment
 Displaced comminuted fractures need a plate and often bone
graft.
 Following operation, early mobilization should be encouraged.

32. Main Complications
Stiffness
Non-union due to inadequate reduction and
fixation.
Ulnar nerve symptoms can develop.
Osteoarthritis

33. Radius and Ulnar bones

34. 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

35. Clinical features
Obvious fractures due to deformity
Check for the five P’s
i. Pulselessness
ii. Pallor
iii. Pain
iv.Paresthesia
v. Paralysis

36. 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

37. X-ray images of the forearm

38. 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.

39. 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

40. 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

41. Plate and screws

42. 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.

43. Complications
Early complications
Nerve injuries
Vascular injury
Compartment syndrome
Late complications
Delayed union and nonunion
Malunion and cross union
Complications of plate removal

44. 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

45. 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.

46. 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.

47. Isolated fractures of the forearm

48. 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)

49. 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

50. 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.

51. 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.

52. Monteggia Fracture X-ray

53. 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

54. TREATED MONTEGGIA FRACTURE

55. Ulnar Fracture
Hume fracture - a fracture of the
olecranon with an associated
anterior dislocation of the radial
head

56. 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.

57. 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.

58. 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

59. Reduced Galeazzi Fracture

60. Complications
Malunion because the distal fragment has no
longitudinal support
Cross union
Compartment syndrome

61. 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.

62. 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

63. 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

64. 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.

65. Salter Harris Classification

66. References
 Apley’s System of Orthopedics and Fractures