SUPRACONDYLAR FRACTURE HUMERUS.pptx

INJURIES AROUND ELBOW
 Elbow injuries are of importance as,
 They are very common children
 Complications like volkmanns isheamic
contracture and myositis ossificans.
 The injuries in the elbow region are described
under-
- Fractures of the distal end of the humerus
- Dislocations of the elbow.
- Fractures of the proximal ends of the radius and
ulna.

FRACTURES OF DISTAL END OF HUMERUS:
 These include:
 Supracondylar fracture
 Intercondylar fracture humerus
 Fracture of the lateral condyle
 Fracture of medial epicondyle
 Fracture of the capitulum.

SUPRACONDYLAR FRACTURE
HUMERUS
 Supracondylar fracture occurs most commonly in
children between the age of 5 and 15 yrs.
 It is caused by a fall on the outstretched hand.
 TYPES:-
 Extension type: This is the most common type
where in the distal fragment is displaced
backwards.
 Flexion type: This is a rare type in which the distal
fragment is displaced forwards.

CLINICAL FEATURES
 Swelling around the elbow
 Severe pain and tenderness in the distal
end of humerus
 Movements of elbow are painful and
restricted.
 The elbow is held in flexed position.
 the fracture occurs above the level of
condyles and the distal fragment is
displaced backwards, upwards and
laterally

.
 This fracture can be differentiated from
posterior elbow dislocation, as the
normal triangular relationship between
the medial epicondyle,the lateral
epicondyle and the olecranon is not
disturbed.
 Check for radial pulsations, as there may
be pressure on brachial artery.

Radiological features
 In AP View:-
- The fracture line runs transversely just above
the condyles of the humerus.
- The distal fragment is displaced and rotated
laterally.
- In lateral view:-
- The line runs upwards and backwards
- The lower fragment is displaced backwards
and upwards and tilted posteriorly.

10/27/2024
NKG
Fat pad sign/ extension type

Classification
 Based on x rays, Gartland has classified
supracondylar fractures as-
 Type 1: undisplaced
 Type 2: partially displaced but posterior
cortex intact
 Type 3: complete displacement in both
AP and Lat views

Treatment:-
 Undisplaced fractures need only a
posterior slab for about 2-3 wks.
 Displaced fractures need reduction with
traction, counter traction and local
pressure and a posterior slab.
 Unstable fracture requires open
reduction and internal fixation.

Complications
 Early :
- Occur at the time of injury or
immediately after,
- Injury to the median nerve,
- Injury to the brachial artery (volkmanns
ischaemia)- needs emergency
management.

.
 Late complications:
1)Cubitus varus deformity:
the most common complication of this
fracture is malunion leading to cubitus varus
deformity,also called gunstock deformity.
- corrected by supracondylar osteotomy
(french osteotomy)
2) Myositis ossificans

INTERCONDYLAR FRACTURE
HUMERUS
 Occurs commonly in adults due to fall on the
point of elbow.
 According to the shape of fracture lines can be
called as ‘T or Y’ fractures.
 Clinically, there will be swelling and on palpation
lower end of humerus is broadened.
 Treated by manipulation and posterior plaster
slab for 2-3 wks, as this involves articular surface
early movements are encouraged.
 Grossly displaced fractures require open
reduction and internal fixation.

Complications
 Elbow stiffness :
 Common complication due to intra
articular nature of the fracture.
 Treated by physiotherapy.
 Malunion :
 Common complication leading to
deformities of elbow
 Treated by corrective osteotomies.

FRACTURES OF MEDIAL EPICONDYLE
 It is an avulsion fracture caused by forceble valgus injury
to the elbow.
 Occurs commonly in children and adolescents.
 Mostly associated with elbow dislocation and ulnar nerve
injury.
 The valgus force can produce the following grades of
injury:-
 1) Sprain or rupture of medial ligament.
 2) Fracture of medial epicondyle with no displacement.
 3) Avulsion fracture with downward displacement
 4) Avulsion of medial epicondyle with marked
downward displacement and inclusion in the elbow joint.

.
 Clinically there will be swelling over the medial
side of the elbow.
 Radiographs will show the avulsed fragment of
the medial epicondyle lying as a loose body.
 Treatment:
 Grade 1&2 : immobilisation in posterior plaster
slab for 3 wks.
 Grade 3 : manipulation done to reposition the
fragment.
 Grade 4 : manipulation is attempted but
surgical repositioning is required.

FRACTURE OF THE LATERAL CONDYLE
OF HUMERUS
 It is a rare fracture occuring in children
due to various types of voilence.
 The fractured fragment includes the
epiphysis of capitellum and the lateral
condyle.
 The common extensor muscles origin
from lateral condyle, the fragment is
pulled downwards and rotated outwards
and backwards.

.
 Clinically, there is swelling and
tenderness over the lateral aspect.
 Classification :
 Milch has classified these fractures as
types1 and 2 based on the fracture line.
 Type 1 : this is less common type, the
fracture line extends lateral to the
trochlea and into the capitotrochlear
groove. The elbow is stable.
 Type 2 : this is more common type, the
fracture line extends in to the apex of
the trochlea. The elbow is unstable.

Treatment :
 Undisplaced fractures – closed reduction
and above elbow slab for 3wks.
 Displaced fractures – more common,
open reduction and internal fixation with
a ‘k’- wire is done.

Complications:
 Non union: it is very common as the fragment is
pulled down and rotated.
 Treated by surgical reduction and fixation.
 Cubitus valgus deformity : this is due to
damaged and arrested growth of lateral part of
the epiphyseal plate.
 The valgus deformity is progressive and later
results in stretching of ulnar nerve and its paralysis
(tardy ulnar nerve palsy)
 Needs surgical anterior transposition of the nerve
and corrective osteotomies.

FRACTURE CAPITELLUM
 This is a rare fracture, wherein the anterior
segment of the capitellum is fractured in the
coronal plane and gets displaced upwards.
 Caused by direct force transmitted from the
radius to the capitellum by a fall.
 Lateral radiograph shows segment of
capitellum displaced upwards in front of the
elbow joint.
 Treatment requires surgical repositioning and
fixation.

Elbow Anatomy
 Three distinct joints
› humeral(trochlea) – ulnar
› humeral(capitellar) –
radial
› proximal radial-
ulnar(PRUJ)

DISLOCATION OF ELBOW
JOINT
 Commonly seen in young adults
 Caused by a fall on outstreched hand.
 Two common types of dislocation are:
-Posterior Dislocation
-Posterolateral Dislocation
 Other types include,
-Posteromedial
-Divergent
-Anterior

.
 1) Posterior dislocation:
 this is the most common type,
 in this type the proximal end of ulna and
radius are displaced posteriorly.
 2)Posterolateral dislocation:
 this type which is common, in addition
to the posterior displacement, the radius
and ulna are displaced laterally

Clinical features
 The elbow is swollen with prominence of
olecranon posteriorly with a depression just
above it due to forward displacement of distal
end of humerus.
 The normal triangular relationship between the
two epicondyles and the olecranon is altered.
 RADIOLOGICAL FEATURES
 AP and Lateral x-rays are taken to confirm the
dislocation

Definition
 Traumatic Elbow Instability
› Combination of fractures and ligament
injuries that destabilize the elbow
The variety of injuries can seem overwhelming……

Simple Elbow Dislocation
Definition
 Dislocation of the
elbow
 No associated
fractures

Treatment
 Reduction is done under general anaesthesia and
a padded posterior slab is applied with the elbow
in a safe degree of flexion.
 COMPLICATIONS:
 EARLY:
 Injury to brachial artery,median or ulnar nerves.
 Fractures of medial epicondyle or the coronoid
process.
 LATE:
 Myositis ossificans
 Joint stiffness

PULLED
ELBOW
 Pulled elbow is a traumatic subluxation of the
radial head in children between 2-6 yrs of age.
 The child presents with pain in elbow and
inability to use the whole upper limb and
tenderness at the proximal end of the radius.
 Treatment is done by simple manipulation of
the forearm into supination with the elbow
stabilised. There is a palpable click, pain
disappears and the normal movement is
restored immediately.

Fractures of the proximal end of
the radius
 These fractures include :-
 1) Fractures of the head of the radius
 2) Fractures of the neck of the radius
 3) Epiphyseal separation in children.
 Mechanism :
 Common in adults, caused by forcible valgus
strain which forces the head of the radius
against the capitellum and causes a fracture
of one or both.

Masons classification
Type I: Nondisplaced 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)
2)

classificatio
n
 Mason has classified radial head fractures as:-
 Type 1 : undisplaced
 Type 2 : marginal fracture with displacement
 Type 3 : comminuted fracture
 Type 4 : fracture associated with elbow dislocation.
 Clinical features include :-
 Swelling around elbow
 Tenderness over the head of radius
 Supination and pronation are painful and restricted.

Radiological features
 Radiological features are of the following heads:-
 Crack fracture of the head
 Fracture of the head with displacement of the
segment
 Comminuted fracture of the head
 Crack fracture neck of the radius
 Fracture neck of the radius with tilting of the head
 Epiphyseal separation of the upper end of the
radius in children

Treatment
 Undisplaced fractures:- immobilisation in
above elbow plaster slab for 3 wks
 Other types with comminution or gross tilt
are treated by radial head excision.
 Recently surgical replacement with silastic
prosthesis of the head is being done after
excision with good results.
 In children with epiphyseal separation,
excision is not done as it will result in
cubitus valgus and tardy ulnar nerve palsy.
 Myositis ossificans is a common
complication of this fracture.

Fractures of the proximal end of
the ulna
 Fractures of proximal end of ulna include
that of olecranon process.
 Occurs due to fall on the flexed elbow.
 The olecranon is fractured ususlly at the
base and the fragment gets pulled
upwards by the insertion of the triceps
tendon.
 The radiograph shows the level of fracture
line and the amount of displacement.

Immobilisation in full extension
If minimally displace
Displaced ,unstable – tension band wiring don
or with lag screw

Treatment
 Undisplaced fractures: immobilisation of
elbow in the above elbow plaster cast is
done with an angle of 20-30 deg of
flexion for 3wks.
 :Displaced fractures open reduction and
internal fixation by tension band wiring
are done.

 The radius and ulna are fractured either by fall on
outstretched hand or by direct injury.
 It is more common in adults
 In children greenstick type of fracture is more
common.
 In fracture of bothbones of forearm restoration of
the interosseous space by proper correction of
overriding, angulation,and rotation is very
important.
FRACTURES OF BOTHBONES OF FOREARM

 Deformity
 Swelling, and
 Abnormal mobility.
 RADIOLOGICAL FEATURES
 A radiograph will show the level of fracture,the
amount of overriding and rotation of fragments
by the alteration of interosseous space.
 Seen through;
 AP Views and,
 Lateral views.
Clinical features

 Non operative
 The undisplaced fractures are treated with above
elbow cast with elbow in 90 deg flexion.
 Closed reduction and plaster immobilisation.
 Displaced fractures of radius and ulna need
manipulative reduction and an above elbow
plaster slab is applied.
 Open reduction and internal fixation:
 Unstable fractures and those with soft tissue
interpositions require open reduction and internal
fixation.
Treatment:

Surgical Treatment
of Forearm Fractures
 Indicated - All Unstable Forearm Fractures and
All Open Forearm Fractures
› Very Few stable enough to treat
nonsurgically in adults
› Most girls >10y/o and boys >12y/o require
surgery
 Options:
› External Fixation
› Intramedullary Rods
› ORIF with Plates

 The development of locked
intramedullary nail systems has
expanded the role of forearm nails in the
management of diaphyseal forearm
fractures .

 Volkmann’s ischaemic contracture- occurs due to tight
bandging or use of unpadded plaster casts as primary
treatment.
 Non union- mostly occurs due to interposition of
pronator teres tendon fibers through the site of radial
fracture.
- Treated by open reduction and internal fixation.
- Malunion: union of fragments with angulation is very
common resulting in deformity and limited pronation
and supination.
- Cross union: occurs when fractures are comminuted
and at the same level.
- Here the radius unites with ulna and ulna unites with the
radius or both are joined by callus.
- Treated by open reduction, realignment and internal
fixation.
Complications

 Monteggia fracture dislocation is a fracture of the
proximal third of the ulna with a dislocation of the
head of the radius.
 Occurs commonly in adults.
 Due to fall associated with forcible pronation of the
forearm or a direct voilence on the posterior
aspect of the proximal forearm.
MONTEGGIA FRACTURE
DISLOCATION

 Type 1(extension type):
 Fracture of the ulna diaphysis with an anterior
angulation at the fracture site and anterior dislocation
of the radial head.
 Type 2 (flexion type):
 Fracture of the ulna diaphysis with an posterior
angulation at the fracture site and the posterior
dislocation of the radial head.
 Type 3 (adduction type):
 Fracture ulna at the metaphysis with a lateral
dislocation of the radial head.
 Type 4:
 Fracture of the proximal third of the ulna and radius at
the same level with an anterior dislocation of the radial
head.
Classification (by Bado)

Monteggia Fractures
Case Example
 ulnar fracture & radial head dislocation
 Treatment requires stable fixation of the ulna &
reduction of the radius

 In the common extension type,
 Presents with pain and swelling in the elbow
and proximal forearm.
 Radial head can be felt in the cubital fossa.
 Tenderness over the proximal ulna with
depression at the fracture site due to forward
angulation.
 Look for evidence of posterior interosseous
nerve palsy which causes finger and thumb
drop
Clinical features

 Radiological features:
 It confirms the type and displacement of the head of the
radius.
 Treatment:
 Closed reduction by realigning the ulna and repositioning
the head of the radius and immobilising the limb in flexion
can be done.
 If this fails, then open reduction is needed to reduce and
internally fix the fracture of the ulna and reduce the
dislocated head of radius.
.

 Malunion:
 Results from conservatively treated
cases.
 Can be treated by open reduction and
ineternal fixation for the ulna.
Complications:

 In this injury, there is a fracture of the distal shaft of
the radius associated with a dislocation of the ulna.
 Clinically, there is deformity and tenderness at the
fracture site and prominence of the dislocated
head of the ulna.
 A radiograph will show the fracture displacement
and dislocation.
 Treated by manipulation and plaster with forearm
in supination.
 Unstable fracture needs open reduction and
internal fixation.
GALEAZZI FRACTURE DISLOCATION

Galleazi Fracture
Case Example
 Galleazi Fracture:
› Distal Radius Fracture with Disruption DRUJ
 Galleazi fracture is best treated
with ORIF
 DRUJ was stable after
reduction so did not require
separate fixation

SUPRACONDYLAR FRACTURE HUMERUS.pptx

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