Elbow fractures and dislocations

ELBOW FRACTURES/ DISLOCATIONS

TRINITY ANGONI

ELBOW FRACTURESDistal humeral fracturesCapitulum fracturesHead of radius fracturesRadial neck fracturesOlecranon process fracturesCoronoid process fractures

Distal humeral fractures

Ao – asif group classification Type A – an extra-articular supracondylar

fracture; Type B – an intra-articular unicondylar

fracture (one condyle sheared off); Type C – bicondylar fractures with

varying degrees ofcomminution.

Capitulum fractures

Bryan and Morey classificationType I: Hahn-Steinthal fragment. Large

osseous component of capitellum, sometimes with trochlear involvement

Type II: Kocher-Lorenz fragment. Articular cartilage with minimal subchondral bone attached: “uncapping of the condyle”

Type III: Markedly comminuted

Head of radius fractures

Mason classification Type I An undisplaced vertical split in the

radial head Type II A displaced single fragment of the

head Type III The head broken into several

fragments (comminuted).

Radial neck fractures

A fall on the outstretched hand forces the elbow into valgus and pushes the radial head against the capitulum.

In children the bone fractures through the neck of the radius; in adults the injury is more likely to fracture the radial head.

Olecranon process fractures

Two broad types of injury are seen: (1) a comminuted fracture which is due to a direct blow

or a fall on the elbow(2) 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 (a) Displaced (b) Undisplaced fractures. More severe injuries may be associated alsowith subluxation or dislocation of the ulno-humeraljoint.

Olecranon process fractures

Morrey Classification Type I: Undisplaced, stable fractures Type II: Displaced, stable Type III: Displaced, unstable fractures

Coronoid process fractures

Regan and Morrey classification Type I: Fracture avulsion just the tip of the

coronoidType II: Those that involve less than 50% of

coronoid either as single fracture or multiple fragments

Type III: Those involve >50% of coronoidSubdivided into those (A)without elbow dislocation(B)with elbow dislocation

Treatment

Surgical treatment is given as appropriate

Plates and screws for comminuted fractures

Headless or lag screws for uncomminuted fractures

Collar and cuff for splinting or other splints in non surgical intervention.

Physiotherapy mx

Problems Stiffness of the elbow Loss of extension and flexion and

sometimes pronation and supination Pain Myositis ossificans Vascular insufficiency Nerve damage (ulnar and median nerve) Mul union

Physio mx

Problems Delayed union Non union Elbow instability Muscle spasm Muscle weakness Muscle atrophy Joint deformity Bone infection (osteomyelitis) Osteoporosis loss of bone density as a result of reduced

functionality Thrombus formation

Physio mx

Ultrasound to loosen adhesions/ myositis ossificans

Massage (hacking) and muscle stretch to realese contractures

Range of motion exercizes to increase extension, flexion, supination and pronation.

Tens/ift for pain medication and muscle spasm.

Physio mx

Circulatory exercizes for vascular insufficiency

Nerve glides for nerve damage if neuropraxic

Nerve stretching Immobilisation in cast in cases of mal

union, delayed union and non union then refere for re assesment.

Immobilising in armsling for elbow instability. Untill healing takes place.

Muscle strengthening exercizes for muscle weakness, muscle atrophy and immobility osteoporosis.

Order for a check x-ray if there is joint deformity for appropriate progression of therapy.

with chronic uhealing wounds discharging pus suspect osteomyelitis, and recommend biopsy for microbiology examination.

tubi grip will be appropriate for dvt (paget von schruetter disease).

ELBOW DISLOCATION

Elbow dislocations

Posterior/ posterolateral Forward dislocation (side swipe) Lateral Anterior

Dislocations

General• The most common type of dislocation in

children and the second most common type in

adults, second only to shoulder dislocation• Young adults between the ages of 25–30

years are most affected and sports activities

account for almost 50% of these injuries• Mechanism: Fall on the outstretched hand

Clinical• Dislocation can be anterior or posterior

with posterior being the most common, occurring

98% of the time.• Associated injuries include fracture of

the radial head, injury to the brachial artery and median nerve

Isolated dislocation of radial head A true isolated dislocation of the radial head is

very rare; if it is seen, search carefully for an associated fracture of the ulna (the Monteggia fracture).

In a child, the ulnar fracture may be difficult to detect if it is incomplete, either green-stick or plastic deformation of the shaft;

it is very important to identify these incomplete fractures because even a minor deformity, if it is allowed to persist, may prevent full reduction ofthe radial head dislocation.

Symptoms• Inability to bend the elbow following a

fall on the outstretched hand• Pain in the shoulder and wrist• On physical exam: The most important

part of the exam is the neurovascular evaluation of

the radial artery, and median, ulnar and radial nerves

Imaging• Plain AP and lateral radiographs• CT and MRI scans are seldom necessary

Treatment• Reduce dislocation as soon as possible

after injury• Splint for 10 days• Initiate ROM exercises, NSAIDs

Complications • Loss of ROM of elbow especially

extension• Ectopic bone formation• Neurovascular injury• Arthritis of the elbow

References

Apley orthopaedic textbook Upper limb fractures Physical medicine and rahabilitation