EPIDEMIOLOGY Accounts for 11% to 28% of injuries to the elbow. Posterior dislocation is most common. Simple dislocations are those without fracture. Complex dislocations are those that occur with an associated fracture and represent just under 50% of elbow dislocations. Highest incidence in the 10- to 20-year old age group associated with sports injuries
MECHANISM OF INJURY Anterior dislocation: A direct force strikes the posterior forearm with the elbow in a flexed position. Posterir dislocation:combination of elbow hyperextension,valgus stress and forearm supination Capsuloligamentous structures of elbow may be injured which progress from medial to lateral
CLINICAL FEATURES• pain• gross swelling• deformity-s shaped• tenderness• abnormal mobility• decreased range of motion
CLINICAL EVALUATION• Elbow joint shows gross swelling and instability• 3 point bony relationship is lost• Neurovascular examination especially vascular compromise should be looked for before and after manipulation or reduction
ASSOCIATED INJURIES• Associated fractures of the radial head or the coronoid process of the ulna may be present• Uncomonly the ulnar nerve and anterior interroseus branch of the median nerve may be involved
RADIOGRAPHIC EVALUATION• Standard anteroposterior and lateral radiographs of the elbow should be obtained.
CLASSIFICATION Simple versus complex (associated with fracture) According to the direction of displacement of the ulna relative to the humerus : Posterior Posterolateral Posteromedial Lateral Medial Anterior
TREATMENT PRINCIPLES Restorationof inherent bony stability of the elbow joint trochlear notch(coronoid and olecranon ) radial head lateral collateral ligament more imp than MCL the elbow should not redislocate before reaching 45 degrees of flexion from a fully flexed position the elbow should be able to go to 30 degrees before substantial subluxation or dislocation
TREATMENT Simple Elbow Dislocation Nonoperative Under sedation and adequate analgesia correction of medial or lateral displacement followed by longitudinal traction and flexion is usually successful for posterior dislocations (parvins method /meynquigleys method Check neurovascular status and range of motion Postreduction radiographs are essential. Postreduction management should consist of a posterior splint at 90 degrees and elevation. A hinged elbow brace through a stable arc of motion may be indicated in cases of instability without associated fracture. Recovery of motion and strength may require 3 to 6 months
Operative Unstable elbow The elbow cannot be held in a concentrically reduced position redislocates before postreduction radiography Dislocates later in spite of splint immobilization We can do (1) open reduction and repair of soft tissues back to the distal humerus (2) hinged external fixation (3) cross-pinning of the joint.
COMPLICATIONS Loss of motion (extension): This is associated with prolonged immobilization. Neurologic compromise: Exploration is recommended if no recovery is seen after 3 months following electromyography. Vascular injury: The brachial artery is most commonly disrupted during injury. If, after reduction, perfusion is not reestablished, angiography is indicated to identify the lesion, with arterial reconstruction when indicated.
COMPLICATIONS Compartment syndrome(volkman contracture)Myositis ossificansDue to excessive manipulation and soft tissue injuryIndomethacin and local radiation therapy prophylacticallyInstability associated with terrible triad of elbow
INTRODUCTION• COMMON IN ATHLETS• SIDE SWIPE INJURIES• DIRECT BLOW ON THE ELBOW WHEN FALL OFF SKATE BOARD• HIGH ENERGY TRAUMA OCCURS IN MOTOR CYCLE COLLISION• ANY OTHER DIRECT INJURY TO ELBOW, HAND, WRIST, OR SHOULDER CAN AFFECT THE ELBOW TOO
SYMPTOMS• HISTORY OF TRAUMA• PAIN• SWELLING• MOVEMENTS OF THE JOINT PAINFUL, DECREASED• WRIST PAIN (ESSEX-LOPRESTI INJURY
MASON CLASSIFICATION• Type I: Non-displaced fractures• Type II: Marginal fractures with displacement (impaction, depression, angulation)• Type III: Comminuted fractures involving the entire head• Type IV: Associated with dislocation of the elbow (Johnston)
TREATMENT GOALS• Correction of any block to forearm rotation• Early range of elbow and forearm motion• Stability of the forearm and elbow• Limitation of the potential for ulnohumeral and radiocapitellar arthrosis, although the latter seems uncommon
TREATMENTNonoperative• Most isolated fractures of the radial head can be treated non-operatively.• Symptomatic management consists of a sling and early range of motion, 24 to 48 hours after injury, as pain subsides.• Aspiration of the radiocapitellar joint with or without injection of local anesthesia has been advocated by some authors for pain relief.
OPERATIVE• Except Mason type I• ORIF with screw• KOCHER’S Approach for radial head #• Excision of radial head• MAC LAUGHLIN’S CRITERIA for immediate excision: 1. Angulation >30° 2. Depression>3mm 3. Involvement of head >1/3 rd
Type III:• Radial head excision is indicated with in first 24 hrs.• Excised head is replaced with prosthesis Type IV:• Prompt reduction of the dislocation is must• Assess status of the head. If it meets the Mac Laughlin’s criteria for excision, do it within 24 hrs.
COMPLICATIONS• Injury to posterior interosseous nerve• Osteoarthritis• Elbow stiffness
OLECRANON FRACTURE• Uncommon in children• Comparable to # patella• Mechanism of injury: DIRECT: Fall on the point of elbow INDIRECT: Forcible triceps contraction
MAYO CLASSIFICATIONType I: Fractures are nondisplaced or minimally displaced and are subclassified as either noncomminuted (type 1A) or comminuted (type 1B). Treatment is nonoperative.
Type II: Fractures have displacement of the proximal fragment without elbow instability; these fractures require operative treatment. – Type IIA fractures, which are noncomminuted, can be treated by tension band wire fixation. – Type IIB fractures are comminuted and require plate fixation
TREATMENT• Avulsion # - TBW/LS• Transverse# - TBW/LS• Transverse# with comm.- Plate& Screws with Bone grafting• Oblique #: Plate/LS• Communition#: Plate/TBW/Excision• Fracture Dislocation: Wire/LS/Plate• Extensile posterior approach
COMPLICATIONS• Hardware failure occurs in 1% to 5%.• Infection occurs in 0% to 6%.• Pin migration occurs in 15%.• Ulnar neuritis occurs in 2% to 12%.• Heterotopic ossification occurs in 2% to 13%.• Nonunion occurs in 5%.• Decreased range of motion: This may complicate up to 50% of cases
Fracture neck of radius• Constitutes 5-10% of all elbow #s• Mech of injury fall on outstretched hand with elbow extended and forearm supinated.• Associated with post dislocastion of elbow prox radial physis (salter haris type II)