Elbow injuries

DR M IMRAN KHAN POSTGRADUATE TRAINEE

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

Movements
Extension (to 0 degrees)
o
o o o

Gravity plus triceps

Biceps and brachialis Pronator teres and pronator quadratus Biceps and supinator

Flexion (145 degrees)

Pronation (75 degrees)

Supination (80 degrees)

Come Read My Tale Of Love Capitellum, Radial head, Medial epicondyle, Trochlea, Olecranon, Lateral epidondyle Age 1, 3, 5, 7, 9, 11 Mettler: Essentials of Radiology, 2nd ed., Copyright 2005 Saunders, An Imprint of Elsevier

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

Anterior humeral line Radiocapitellar line points 1/3 capitellum middle directly to Disruption = capitellum displaced fracture

Fat pad sign may be only clue if non-displaced

FAT PAD SIGN

 Fat Pad sign (aka. Sail Sign)

Anterior fat pad sign can be normal o Posterior always abnormal
o

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 normally passes 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 o o o
o

Evaluation:
o

AP Oblique Lateral Elbow in 90 degree flexion Compare with opposite elbow

Technique:

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 doesnt intersect, this is a sign of dislocation)

Fracture over olecranon

Mechanism -fall on point of elbow -sudden triceps contraction Dont 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, OBrian and Jeffery. Wilkin combined classification of Newman and Jeffery. A- SH I or II B- SH IV C- Metaphysical fracture D- 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: Milch Roentgenographic Amount of displacement.

MILCH CLASSIFICATION

1- TYPE I (Salter n Harris-IV) 2- TYPE-II (Salter n Harris-ii)

Roentgenographic Classification
Minimal Lateral Gap Average Lateral gap Fracture 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.

THANK YOU