Elbow trauma & infection

D R N A R E N D E R S A I N I
AS S I S T. P R O F,
U N I T O F H AN D S U R G E RY,
D E PAR T M E N T O F O R TH O PAE D I C S ,
S M S M E D I C AL C O L L E G E AN D AT TA C H E D G R O U P S O F
H O S P I TAL S ,
J AI P U R .
Overview of
Elbow Trauma & Infections.
Sunday,May 1, 2016PG Teaching RRC

Elbow
Overview
Trauma Infection

Elbow Trauma
 6% of all fractures and dislocations involve elbow
 Most common fractures differ between adults and
children
 M.C. in adults- radial head and neck Fracture
 M.C. in children- supracondylar fracture.
 Complex anatomy requires 4 views for adequate
interpretation
 AP in extension, medial oblique, lateral and axial olecranon
(Jones view)

Elbow Trauma
Pediatric Adult

Pediatric Elbow Injuries
Condylar Fractures
Lateral Medial
Supracondylar
fractures
Inter/ Epi Condylar
Fracture

Normal Elbow Anatomy
 Very important to be aware of pediatric growth
centers
 CRITOE
http://med_practice.byethost7.com/wp2/?p=21 http://www.radiologyassistant.nl/en/4214416a75d87

Normal Alignment
 Anterior humeral line- line drawn along anterior
surface of humeral cortex
should pass through the middle
third of the capitellum
 Radiocapitellar line- Line
drawn through the proximal
radial shaft and neck
should pass through to
the articulating capitellum

Signs of Fracture
 Usual signs may not be readily visible
 Fracture line, cortical disruption, etc.
 Soft tissue signs can indicate fracture
 Fat pad sign
 On lateral, might see fat pad parallel to anterior humeral cortex,
and posterior cortex
 With effusion, Posterior may be displaced

Fat Pad Sign
 Posterior fat pad is normally buried in olecranon
fossa and not visible
 Becomes elevated and visible with joint uffusion
 Effusion (acute capsular swelling) can be from any origin
(hemorrhagic, inflammatory, infectious, traumatic, etc.)
 Ant. fat pad may be obliterated, so post. Fat pad is
more reliable when visible

Distal humerus fractures
 95% extend to articular surface
 Classified according to relationship with condyle and
shape of fracture line
 Supracondylar, intercondylar, condylar and epicondylar

Supracondylar Fractures
 Most common elbow fracture in children (60%)
 Fracture line extends transversely or obliquely through
distal humerus
above the condyles
 Distal fragment usually
displaces posteriorly
Normal

Intercondylar fracture
 Fracture line extends between medial and lateral
condyles and extends to supracondylar region
 Results and T or Y shaped configuration for fracture
 Called trans-condylar if it extends through both
condyles

Epicondylar fracture
 Usually avulsion from traction of respective common
flexor (medial) or extensor (lateral) tendons
 Medial epicondyle
avulsion common in
sports with strong
throwing motion
(little leaguer’s elbow)

Fractures of Proximal Ulna
 Olecranon fx.- direct trauma or avulsion by triceps
tendon
 Coronoid process fx.- avulsion by brachialis or
impaction into trochlear fossa
 Rarely isolated;
usually associated
with post. elbow
dislocation

Fractures of Proximal Radius
 M.C. adult elbow fx. (50%) (Radial neck in young)
 FOOSH transmits force causing impaction of radial
head into capitellum
 Chisel fracture- incomplete fracture of radial head
that extends to center of
articular surface
 Usual rad. signs (fx. Line, articular
disruption) may not be visible
 May be occult; fat pad sign is good
indicator of occult fx.

Dislocations of Elbow
 3rd m.c. dislocation in adults behind shoulder and
interphalangeal joints
 More common in children
 Classified according to displacement of radius an
ulna relative to humerus
 Posterior, posterolateral, anterior, medial and
anteromedial
 Posterior and posterolateral or more most common
 85-90% of all elbow dislocations
 50% have associated fractures

Pulled Elbow
 Nursemaid’s elbow
 Occurs when child’s hand is pulled, traction
causes radial head to slip out from under annular
ligament and trapping the ligament in the
radiohumeral articulation
 Immediate pain; stuck in mid-pronation due to pain
 No radiographic sign
 Supination reduces the dislocation and ends pain,
usually during positioning of lateral radiograph

Adult Elbow Injuries
Distal Humerus
Type A
Supracondylar
Type R
Unicondylar
Type C
Bicondylar
Proximal Ulna
Coronoid
Fractures
Olecranon
Proximal
Radius
Head Radius Neck of
Radius
Dislocations

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

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.

Types B and C intra articular fractures
 High-energy trauma
 Associated 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

X-ray
 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.

Treatment Displaced type B and C
 ORIF k wires/ Plates/ Screws
 Plates with locking screws

Unicondylar fracture without comminution can then be
fixed with screws; if the fragment is large, a contoured
plate is added to prevent re-displacement

 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

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.

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

Radial Head Fractures:
Modified - Mason Classification
Type I: nondisplaced
 No block to forearm rotation, displacement <
2mm
Type II: displaced
 Internal fixation possible
Type III: displaced, severely comminuted
 Judged to be irreparable
Type IV: fracture + dislocation

Radial Head - ORIF
 One / Two part articular fracture
 Entire head – one piece
 Preserve head when possible

Radial Head – Excise / replace
Fracture not reducable
Osteoporotic
Extraarticular
Elbow stable Elbow Unstable
Excise Replace

Do not excise without replacement
 Restore radial head
 If not possible replace
 Repair lateral collateral lig
 Orif of coronoid

Safe Zone – Radial Heal ORIF
 Forearm neutral rotation
– mark AP diameter
radial head
 Safe zone – 65 deg.
anterior and 45 deg.
Posterior to this mark

Radial head replacement
 Overstuffing – early joint degeneration
 Understuffing – Valgus instability
 Intraop – visible ulnohumeral gap – suggests radial
lengthening.

Coronoid fracture
 Classification
- Regan and Moorey
- O’ Driscoll

Coronoid Fracture – Regan & Moorey Classification
 Type 1 - # tip
 Type 2 - < 50 %
 Type 3 - >50%

Classification: Coronoid fractures
O’Driscoll Classification
Type I: Tip
Type II: Anteromedial facet
Type III: Base

Coronoid fractures—nonoperative treatment
Type I
 Usually early motion
Type II
 Early motion, unless unstable
 Internal fixation if associated injuries

Coronoid fractures—surgical treatment
Type III
 Internal fixation
 Screw or anterior plate
 Reconstruction with bone
graft (tip of olecranon)

Coronoid fracture – Associated condition
 Posteromedial rotatory instability
 Posterolateral rotatory instability
 Terrible triad
 Large fracture of olecranon

Coronoid fracture
 Small fragments – Type 1
 Fix with suture - non absorbale suture

Coronoid fracture
 Type 2 ( < 50%)
 Type 3 ( >50%)
Fix with screw passed from
ulnar cortex
Large fragment – plate
fixation – medial
approach

Lateral Collateral Ligament Complex
 Avulsed from lateral condyle along with common
extensor
 Unstable elbow to varus test
 Local bruising

Lateral Collateral ligament
 Repair with suture
anchors
 Transosseous tunnels

Medial Collateral ligament
 After repairing radial head
 Coronoid
 LCL
 Test elbow stability – Fluoroscopically
 Elbow unstable from 30 to 130 – repair MCL

Terrible Triad: Medial Instability ?
 Repair MCL
 Reconstruct through bone tunnels
 Suture Anchors
 Palmaris autograft or allograft tendon
 Repair muscle origins
Ulnohumeral joint
reduced

Simple dislocations
 Universal disruption of the LCL
 MCL partially or completely torn
Bony congruence
 Secondary stabilizers intact
 Recurrent instability rare

Stabilizers of elbow
 Primary stabilizers
Ulnohumeral joint
MCL -( Ant. Bundle)
LCL - lateral ulnar
collateral ligament
(LUCL),
 Secondary stabilizers
Radiohumeral joint
Capsule
Origin of flexor & extensor
tendons
Dynamic stabilizers - Muscle crossing elbow
Anconeus
Brachialis
Triceps

Complex fracture dislocations
transolecranon fracture
dislocation
posterior Monteggiadislocation, radial
head, coronoid
TERRIBLE TRIAD

Terrible Triad
 Elbow dislocation
 Coronoid fracture
 Radial head fracture

The “terrible triad“
 Subluxation—ligamentous injury
 Coronoid fracture
 Radial head fracture
 Primary and secondary stabilizers disrupted
 Recurrent instability the rule

Why terrible
 Recurrent / persistent subluxation or dislocation
 Chronic instability
 Arthrosis and pain

Terrible Triad Fracture-Dislocation
 What is so terrible about it?
 Extremely unstable
 Loss of joint congruency
 Instability
 Fracture fragments are usually quite
small
 Difficult to repair
 Prognosis Poor
 Unaware of the magnitude of the
injury for the elbow
 Residual instability
 Stiffness

Mechanism of injury
 Fall on outstretched hand
 Axial load, supination & Valgus stress

Stages
I Ulnar lateral collateral
ligament disruption
II Anterior and posterior
soft issue disruption with
coronoid under trochlea
III a Intact MCL anterior
band
III b Ruptured MCL
anterior band
III c All soft tissue stripped

Terrible triad - Presentation
 Pain
 Clicking
 Locking of elbow in extension
 Varus instability
 Valgus instability – ( If MCL injured )

What are the Dilemna
 Surgical techniques challenging
 Debate in surgical steps
 Choices in management

Critical components to achieve treatment goals
 Obtaining and
maintaining
a concentrically
reduced
articulation
 Management of
coronoid & radial head
fracture if present
 Early range of motion

Examination
 Unstable elbow with wrist injury - High risk of
compartment syndrome
 Combined distal radius and elbow fracture – 9/59 (
15%)
 Isolated distal radius # - 3/869 ( .3%)

 Baseline neural examination
 20% patient – Terrible ulnar nerve palsy

 High risk of developing heterotopic ossification

Management
 Dislocated elbow – reduce in emergency dept
 Unstable – Do not perform repeat rereduction
 Plan under anaesthesia

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

 Bryan and Morrey classify these as:
i. Type I Complete fracture
ii. Type II Cartilaginous shell
iii. Type III Comminuted fracture.

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

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. Sunday,May 1, 2016PG Teaching RRC

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.

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.

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

Elbow Infections
Inflammatory
Infective
Tubercular Septic
Olecranon
Bursitis
Non
Infective
Rheumatoid Others

 Septic arthritis can be caused by bacteria, viruses, and fungi.
 . The most common causes of septic arthritis are bacteria,
including Staphylococcus aureus and Haemophilus influenzae.
 In certain "high-risk" individuals, other bacteria may cause septic arthritis,
such as E. coli and Pseudomonas spp.
 Risks for the development of septic arthritis include taking immune-
suppression medicines, intravenous drug abuse, past joint disease, injury
or surgery, and underlying medical illnesses,
including diabetes, alcoholism, sickle cell disease, rheumatic diseases, and
immune deficiency disorders.
 Symptoms of septic arthritis include fever, chills, as well as joint pain,
swelling, redness, stiffness, and warmth.
 Septic arthritis is diagnosed by identifying infected joint fluid.
 Septic arthritis is treated with antibiotics and drainage of the infected joint
fluid from the joint.

Tubercular Arthritis

Anteroposterior view of elbow showing
stage 2 lesion involving medial epicondyle
only
Anteroposterior and lateral view of elbow
showing stage 3A involvement (limited to
coronoid)
showing stage 3B involvement (joint
involvement without significant destruction)

showing stage 4 involvement (gross joint
destruction with pathological fracture)
Anteroposterior (a) and lateral (b)
radiographs showing bony ankylosis after
anti tubercular chemotherapy

Rheumatoid arthritis:
 an autoimmune disease
 body’s immune system attacks the synovium, or the
tissue lining the joints.
 progressive erosion and destruction of the cartilage
and bone, leading to severe pain, stiffness, and
deformity.

Primary Osteoarthritis:
 cartilage becomes thin over time, the bones begin to
grind against each other on rough surfaces (bone on
bone).
 Bone spurs or osteophytes form inside the joint.
 loose bodies in the joint may cause catching
symptoms as well as accelerate degeneration from
mechanical wear.

Post-traumatic arthritis:
 One of the most common causes of arthritis
 Patients with a prior fracture or dislocation of the
elbow can have cartilage injury, leading to
progressive deterioration of the joint.
 fractures of the distal humerus, radial head fractures,
and olecranon fractures. In complex injuries, there
are often large cartilage defects and deformities of
the elbow, leading to abnormal mechanics and rapid
wear of the joint.

Olecranon bursitis
Inflammation behind the elbow.
The bursa sac experiences some sort of
trauma or blunt force.
.
When it receives a quick blow, it produces
more fluid.
Elbow becomes inflamed and swollen.
Elbow will feel hot and be red in color.

Elbow trauma & infection

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