Elbow injuries

DR M IMRAN KHANPOSTGRADUATE TRAINEE

 

Objectives

• Revise a bit of pathoanatomy• Learn elbow movements• Know common injuries• Know management of those injuries

Movements

• Extension (to 0 degrees)o Gravity plus triceps

• Flexion (145 degrees)o Biceps and brachialis

• Pronation (75 degrees)o Pronator teres and pronator quadratus

• Supination (80 degrees)o Biceps and supinator

 

 

Mettler: Essentials of Radiology, 2nd ed., Copyright © 2005 Saunders, An Imprint of Elsevier

Come Read My Tale Of Love Capitellum, Radial head, Medial

epicondyle, Trochlea, Olecranon, Lateral epidondyle

Age 1, 3, 5, 7, 9, 11

Know basic landmarks on lateral view to give clues to distinguish fracture from normal

• Anterior humeral line—middle 1/3 capitellum

• Radiocapitellar line—points directly to capitellum

• Disruption = displaced fracture

• Fat pad sign may be only clue if non-displaced

    FAT PAD SIGN

 

• Fat Pad sign (aka. Sail Sign)o Anterior fat pad sign can be

normalo Posterior always abnormal

Green: Skeletal Trauma in Children, 3rd ed., Copyright © 2003 Saunders, An Imprint of Elsevier

 

 

Most common injuries

• Supra-condylar fracture• Radial head fracture• Olecranon fracture• Dislocation• Fracture dislocation• Pulled elbow

SUPRACONDYLAR FRACTURE

Broadly divided in to:.Flexion type

.Extension type

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

        Radiographic Evaluation

     3 VIEWS ON AP-VIEW AND 3 VIEWS ON LATERAL VIEW.

   AP View:  Baumann angle- 72 degrees ( should not be >81 degrees)  Humeroulnar shaft angle- carrying angle  Metaphyseal diaphyseal angle- 90 degrees

   LATERAL VIEW  Anterior humeral line  Anterior coronoid line  Humerocondylar angle

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Radial Head Subluxation

• AKA “Nursemaids’ Elbow”• Common injury that is seen most often in

children between the ages of 1-6 years• Occurs when longitudinal traction is

placed on the hand while the elbow is extended and the forearm pronated.

• Usually occurs when child falls and continues to be held by the hand, or when small children are swung by their arms.

Anatomy

• The annular ligament normallypasses around the proximal radius just below the radial head. With traction on the extended arm, the annular ligament slides over the head of the radius into the joint space and becomes entrapped• Common early childhood injury

because at an early age, the radial head is spherical and is composed mainly of cartilage

Clinical Presentation• history of arm being pulled• injured elbow pronated, partially flexed

and held by side, child will not use• there is anterolateral tenderness over the

radial head• no swelling, redness, warmth, abrasions,

or ecchymosis• have been reports of infants < 6 months

old with a history of not using arm after rolling over and their arms getting caught

Radiographs

• Diagnosis is by history and physical examination. Radiograph examination is usually not necessary and are normal in most instances.

• If x-rays are taken, often the subluxation is reduced when the technician positions the arm on the plate.

• Radiographs become necessary if pain continues post-reduction.

Reduction

• Cup affected elbow with opposite hand

• Apply pressure over radial head

• Thumb in antecubital fossa

• Apply slight longitudinal traction by grasping wrist

• Supinate (palm up) and flex (to 90 degrees) forearm

• Palpable click felt with reduction

Post-reduction Management

• Child should be pain-free and use arm within 0-15 minutes. Immobilization optional (Sling for 1-2 days) • If child fails to use arm after 15 minutes, obtain

elbow views to rule out concomitant fracture• If x-rays normal but child still not using arm, use

a posterior splint and sling and re-evaluate in 24 hours

• If child has 3 recurrent episodes of subluxation, then apply hard cast for 3 weeks

Elbow X-ray

• Views: o APo Obliqueo Lateral

• Technique: o Elbow in 90 degree

flexion o Compare with opposite

elbow

• Evaluation:o The radial head should

always point at the capitellum in all views. A line drawn down the long axis of the radius (radial head) should intersect the capitellum in all views (if the line doesn’t intersect, this is a sign of dislocation)

Fracture over olecranon

• Mechanism -fall on point of elbow-sudden triceps contraction

Don’t forget epiphyses

Olecranon fractures

• Hairline and undisplaced fractures can be treated in long arm cast for 3-4 weeks in children and 6-8 weeks in adults

• If fragment large/displaced will require fixation e.g. tension band wiring

Isolated Radial Head Dislocation

• Very rare

• Can occur in children because bones are more plastic.

• Usually anterior, very rarely posterior and lateral.

• ULNAR BOW SIGN by Lincolin and Mubarak.

 

• Usually <1mm

• If more than 1mm show dislocated radial head.

• Also called ‘Minimal Monteggia Fracture’.

• Close Reduction if <3 week old. (Forearm supination + 90 flexion – anterior dislocation, Forearm

pronation + 90 elbow flexion- Posterior dislocation)

• ORIF if > 3 weeks old.

Radial Head and Neck Fracture

• Occur at 4-14 years of age.• Most fractures in children are of radial neck.• Numerous classifications like Rostal, Newman, O’Brian and

Jeffery.• Wilkin combined classification of Newman and Jeffery.

A-    SH I or IIB-    SH IVC-    Metaphysical fractureD-    Fracture occurring when dislocated elbow is reduced.E-     Fracture occurring with elbow dislocation.

 

• After dislocation the fragment can lie loose in the joint or it can be trapped which prevents reduction.

• Between 30-45 angulations is acceptable. Whenever angulations is >45, elbow is maneuvered to reduce it to below 45.

 

•      Patterson technique•       Pesudo technique•       Metaizeau technique•       ORIF via Boyd approach.

Complications:

• Loss of motion.• Pre-mature physeal closure.• No radial neck.• AVN radial head.• RIU synostosis.• Myositis Ossificans.• Injury to posterior interosseous nerve.

Lateral Condyl Fracture• More common than medial epicondyl

and condyl• Quite common.

• Classified by:Ø      MilchØ      RoentgenographicØ      Amount of displacement.

          MILCH CLASSIFICATION

           1- TYPE I   (Salter n Harris-IV)

2- TYPE-II    (Salter n Harris-ii)

 

            Roentgenographic Classification

Minimal Lateral GapAverage Lateral gapFracture gap as wide Laterally as medially   

Amount of Displacement                       (Kay Wupon's classification)  Undisplaced ( 2mm or less dis at metaphyses)Moderately Displaced (2-4mm)Completely displaced (>4mm) and rotated.

                   TREATMENT

                                                                      SPEED AND BOYD

• ORIF for displaced fractures

 • CR with immobilization for undisplaced fractures but close

observation every 5-7 days is necessary.

           BEATY AND WOOD

•  USED VARUS AND VALGUS STRESS TEST TO FIND

OUT IF FRACTURE IS STABLE AND RECOMMENDED

ORIF IF IT DISPLACES WITH STRESS.

                     MINTZER

•     Recommended CR and PCP for fractures

with  minimal   displacement (<2cms) and

congruent joint surfaces.

                         ORIF

• DONE VIA LATERAL APPROACH.• AIM IS TO REPLACE FRAGMENT WITH MINIMAL

DISSECTION AND FIXATION WITH;                    1- Suture which is inadequate and is not recommended.        2- Smoot pins either through epiphyses or metaphysea            spike.        3- Screw fixation - probably through metaphyseal area.            However Conner and Smith used a Glassgow screw           through the physis and epiphyses and didnt notice any            growth disturbance.   

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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