Elbow trauma & infection

DR NARENDER SAINIASS IST. PROF,

UN IT OF HAND SURGERY,DEPARTMENT OF ORTHOPAEDIC S,

SMS MEDICAL COLLEGE AND AT TACHED GROUPS OF HOSP ITALS ,

JA IPUR .

Overview ofElbow Trauma & Infections.

Sunday,May 1, 2016PG Teaching RRC


Elbow Overview

Trauma Infection

Elbow Trauma

6% of all fractures and dislocations involve elbow

Most common fractures differ between adults and children M.C. in adults- radial head and neck Fracture M.C. in children- supracondylar fracture.

Complex anatomy requires 4 views for adequate interpretation AP in extension, medial oblique, lateral and axial

olecranon (Jones view)


Elbow Trauma

Pediatric Adult


Pediatric Elbow Injuries

Condylar Fractures

Lateral Medial

Supracondylar fractures

Inter/ Epi Condylar Fracture


Normal Elbow Anatomy

Very important to be aware of pediatric growth centers CRITOE

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http://www.radiologyassistant.nl/en/4214416a75d87

http://www.radiologyassistant.nl/en/4214416a75d87

http://med_practice.byethost7.com/wp2/wp-content/uploads/2011/07/ElbowAPLabelled.jpg


Normal AlignmentAnterior humeral line- line drawn along

anterior surface of humeral cortex should pass through the middle third of the capitellum

Radiocapitellar line- Line drawn through the proximal radial shaft and neck should pass through to the articulating capitellum


Signs of Fracture

Usual signs may not be readily visible Fracture line, cortical disruption, etc.

Soft tissue signs can indicate fracture Fat pad sign

On lateral, might see fat pad parallel to anterior humeral cortex, and posterior cortex

With effusion, Posterior may be displaced


Fat Pad SignPosterior fat pad is normally buried in

olecranon fossa and not visible Becomes elevated and visible with joint uffusion

Effusion (acute capsular swelling) can be from any origin (hemorrhagic, inflammatory, infectious, traumatic, etc.)

Ant. fat pad may be obliterated, so post. Fat pad is more reliable when visible


Distal humerus fractures

95% extend to articular surfaceClassified according to relationship with

condyle and shape of fracture line Supracondylar, intercondylar, condylar and epicondylar


Supracondylar FracturesMost common elbow fracture in children (60%)Fracture line extends transversely or obliquely

through distal humerus above the condyles Distal fragment usually displaces posteriorly

Normal


Intercondylar fracture

Fracture line extends between medial and lateral condyles and extends to supracondylar region Results and T or Y shaped configuration for fracture

Called trans-condylar if it extends through both condyles


Epicondylar fractureUsually avulsion from traction of respective

common flexor (medial) or extensor (lateral) tendons

Medial epicondyle avulsion common in sports with strong throwing motion (little leaguer’s elbow)


Fractures of Proximal UlnaOlecranon fx.- direct trauma or avulsion by

triceps tendonCoronoid process fx.- avulsion by brachialis or

impaction into trochlear fossa Rarely isolated; usually associated with post. elbow dislocation


Fractures of Proximal RadiusM.C. adult elbow fx. (50%) (Radial neck in

young)FOOSH transmits force causing impaction of

radial head into capitellumChisel fracture- incomplete fracture of radial

head that extends to center of articular surfaceUsual rad. signs (fx. Line, articular disruption) may not be visible

May be occult; fat pad sign is good indicator of occult fx.


Dislocations of Elbow

3rd m.c. dislocation in adults behind shoulder and interphalangeal joints More common in children

Classified according to displacement of radius an ulna relative to humerus Posterior, posterolateral, anterior, medial and

anteromedialPosterior and posterolateral or more most

common 85-90% of all elbow dislocations 50% have associated fractures


Pulled Elbow

Nursemaid’s elbowOccurs when child’s hand is pulled, traction

causes radial head to slip out from under annular ligament and trapping the ligament in the radiohumeral articulation

Immediate pain; stuck in mid-pronation due to pain

No radiographic signSupination reduces the dislocation and ends

pain, usually during positioning of lateral radiograph Sunday,May 1, 2016PG Teaching RRC

Adult Elbow Injuries

Distal Humerus

Type ASupracon

dylar

Type RUnicondyl

ar

Type CBicondyla

r

Proximal Ulna

CoronoidFractures

Olecranon

Proximal Radius

Head Radius

Neck of Radius

Dislocations


Supracondylar fractures type A

Rare in adults. Usually they are displaced and unstableIn high-energy injuries there may be

comminution of the distal humerus


Treatment

Open reduction and internal fixation.Mostly plates and screws are used

Closed reduction is unlikely to be stableK-wire fixation is not strong enough to permit

early mobilization.


Types B and C intra articular fractures

High-energy traumaAssociated with soft-tissue damage. A severe blow on the point of the elbow

drives the olecranon process upwards, splitting the condyles apart.

Swelling is considerable. The patient should be checked for

i. Pulselessnessii. Palloriii. Painiv. Paresthesiav. Paralysis


X-ray

T- or Y shaped break, or else there may be (comminution).


Treatment type Undisplaced fractures

Joint damage- prolonged immobilization will certainly result in a stiff elbow.

Early movement is a prime objective.Treated by applying a posterior slab with

the elbow flexed almost 90 degrees; movements are commenced after 2

weeks.


Treatment Displaced type B and C

ORIF k wires/ Plates/ ScrewsPlates with locking screws



Unicondylar fracture without comminution can then be fixed with screws; if the fragment is large, a contoured plate is added to prevent re-displacement


Postoperatively the elbow is held at 90 degrees with the arm supported in a sling. Movement is encouraged but should never be forced.

Fracture healing usually occurs by 12 weeks. patient often does not regain full extension

Alternative treatmentsElbow replacementThe ‘bag of bones’ technique.

The arm is held in a collar and cuff or, better, a hinged brace, with the elbow flexed above a right angle; active movements are encouraged as soon as the patient is willing. The fracture usually unites within 6–8 weeks, but exercises are continued far longer. A useful range of movement (45–90 degrees) is often obtained.

Skeletal traction the patient remains in bed with the humerus

held vertical, and elbow movements are encouraged.


Complications of supracondylar fractures

Vascular injuryNerve injury median nerveVolkmann’s ischemic contractureMalunion leading to gunstock deformity Myositis ossificansStiffness


Radial Head Fractures:Modified - Mason Classification

Type I: nondisplaced No block to forearm rotation, displacement

< 2mmType II: displaced

Internal fixation possibleType III: displaced, severely comminuted

Judged to be irreparableType IV: fracture + dislocation


Radial Head - ORIF

One / Two part articular fractureEntire head – one piece

Preserve head when possible


Radial Head – Excise / replace

Fracture not reducable Osteoporotic Extraarticular

Elbow stable Elbow Unstable

Excise ReplaceSunday,May 1, 2016PG Teaching RRC

Do not excise without replacement

Restore radial head If not possible replace Repair lateral collateral ligOrif of coronoid


Safe Zone – Radial Heal ORIFForearm neutral

rotation – mark AP diameter radial head

Safe zone – 65 deg. anterior and 45 deg. Posterior to this mark


Radial head replacement

Overstuffing – early joint degeneration

Understuffing – Valgus instability

Intraop – visible ulnohumeral gap – suggests radial lengthening.



Coronoid fracture

Classification

Regan and Moorey

O’ Driscoll


Coronoid Fracture – Regan & Moorey Classification

Type 1 - # tip

Type 2 - < 50 %

Type 3 - >50%


Classification: Coronoid fractures

O’Driscoll ClassificationType I: TipType II: Anteromedial facetType III: Base


Coronoid fractures—nonoperative treatment

Type I Usually early motion

Type II Early motion, unless unstableInternal fixation if associated injuries


Coronoid fractures—surgical treatment

Type IIIInternal fixationScrew or anterior

plateReconstruction with

bone graft (tip of olecranon)


Coronoid fracture – Associated condition

Posteromedial rotatory instability

Posterolateral rotatory instability

Terrible triad

Large fracture of olecranon


Coronoid fracture

Small fragments – Type 1

Fix with suture - non absorbale suture



Coronoid fractureType 2 ( < 50%)Type 3 ( >50%)

Fix with screw passed from ulnar cortex

Large fragment – plate fixation – medial approach


Lateral Collateral Ligament Complex

Avulsed from lateral condyle along with common extensor

Unstable elbow to varus test

Local bruising


Lateral Collateral ligamentRepair with suture

anchors

Transosseous tunnels


Medial Collateral ligament

After repairing radial head Coronoid LCL

Test elbow stability – Fluoroscopically

Elbow unstable from 30 to 130 – repair MCL


Terrible Triad: Medial Instability ? Repair MCL Reconstruct through bone tunnels

Suture Anchors Palmaris autograft or allograft tendon

Repair muscle originsPronator

FCU

Nerve

Medial Epicondyle

FCU Ulnar

Nerve

Medial Epicondyle

Ulnohumeral joint reducedSunday,May 1, 2016PG Teaching RRC

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Simple dislocationsUniversal disruption of the LCLMCL partially or completely torn

Bony congruence Secondary stabilizers intactRecurrent instability rare


Stabilizers of elbowPrimary stabilizers

Ulnohumeral jointMCL -( Ant. Bundle)LCL - lateral ulnar

collateral ligament (LUCL),

Secondary stabilizers

Radiohumeral jointCapsuleOrigin of flexor &

extensor tendons

Dynamic stabilizers - Muscle crossing elbowAnconeusBrachialis

TricepsSunday,May 1, 2016PG Teaching RRC

Complex fracture dislocations

transolecranon fracture dislocation

posterior Monteggiadislocation, radial

head, coronoid

TERRIBLE TRIADSunday,May 1, 2016PG Teaching RRC

Terrible Triad

Elbow dislocation Coronoid fracture Radial head fracture



The “terrible triad“

Subluxation—ligamentous injuryCoronoid fractureRadial head fracture

Primary and secondary stabilizers disrupted

Recurrent instability the rule


Why terrible

Recurrent / persistent subluxation or dislocation

Chronic instability

Arthrosis and pain


Terrible Triad Fracture-Dislocation

What is so terrible about it? Extremely unstable

Loss of joint congruency Instability

Fracture fragments are usually quite small Difficult to repair

Prognosis Poor Unaware of the magnitude of the

injury for the elbow Residual instability Stiffness


Mechanism of injury

Fall on outstretched hand

Axial load, supination & Valgus stress


StagesI Ulnar lateral collateral

ligament disruption

II Anterior and posterior soft issue disruption with coronoid under trochlea

III a Intact MCL anterior band

III b Ruptured MCL anterior band

III c All soft tissue stripped


Terrible triad - Presentation

Pain ClickingLocking of elbow in extension

Varus instabilityValgus instability – ( If MCL injured )


What are the Dilemna

Surgical techniques challenging

Debate in surgical steps

Choices in management


Critical components to achieve treatment goals

Obtaining and maintaining a concentrically reduced articulation

Management of coronoid & radial head fracture if present

Early range of motion


Examination

Unstable elbow with wrist injury - High risk of compartment syndrome

Combined distal radius and elbow fracture – 9/59 ( 15%)

Isolated distal radius # - 3/869 ( .3%)


Baseline neural examination

20% patient – Terrible ulnar nerve palsy


High risk of developing heterotopic ossification


Management

Dislocated elbow – reduce in emergency dept

Unstable – Do not perform repeat rereduction

Plan under anaesthesia


FRACTURED CAPITULUMRare articular fractureMainly occurs in adultsElbow is tender and flexion is grossly restrictedMechanism of injury

The patient falls on the hand, usually with the elbow straight.

The anterior part of the capitulum is sheared off and displaced proximally


X-rays

Bryan and Morrey classify these as:

i. Type I Complete fracture

ii. Type II Cartilaginous shell

iii. Type III Comminuted fracture.Sunday,May 1, 2016PG Teaching RRC

Treatment

Undisplaced fractures can be treated by simple splintage for 2 weeks.

Displaced fractures should be reduced and held.

Closed reduction is feasible, but prolonged immobilization may result in a stiff elbow.

ORIF is therefore preferred.Using headless bone screwsMovements are commenced as soon as

discomfort permitsSunday,May 1, 2016PG Teaching RRC


Fractures of the olecranon Two broad types of injury are seen: i. Comminuted fracture which is due to a direct

blow or a fall on the elbowii. 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

i. Displaced fracturesii. Undisplaced fractures. Subluxation or dislocation of the ulno-humeral

joint in severe injuriesThe fracture always enters the elbow joint and

therefore damages the articular cartilage. Sunday,May 1, 2016PG Teaching RRC

Clinical features

A graze or bruise over the elbow suggests a comminuted fracture; the triceps is intact and the elbow can be extended against gravity.

With a transverse fracture there may be a palpable gap and the patient is unable to extend the elbow against resistance.


TreatmentA comminuted fracture with the triceps intact

should be rested in a sling for a week; then encouraged to start active movements.

An undisplaced transverse fracture that does not separate when the elbow is in flexion can be treated closed.

The elbow is immobilized by a cast in about 60 degrees of flexion for 2–3 weeks and then exercises are begun.

Displaced transverse fracture ORIF is done. The fracture is reduced and held by tension band wiring.

Oblique fractures may need a lag screw, neutralized by a tension band system or plate.Sunday,May 1, 2016PG Teaching RRC

Treatment

Displaced comminuted fractures need a plate and often bone graft.

Following operation, early mobilization should be encouraged.


Elbow Infections

Inflammatory

Infective

Tubercular Septic

Olecranon Bursitis

Non Infective

Rheumatoid Others


Septic arthritis can be caused by bacteria, viruses, and fungi. . The most common causes of septic arthritis are bacteria, including

Staphylococcus aureus and Haemophilus influenzae. In certain "high-risk" individuals, other bacteria may cause septic arthritis,

such as E. coli and Pseudomonas spp.

Risks for the development of septic arthritis include taking immune-suppression medicines, intravenous drug abuse, past joint disease, injury or surgery, and underlying medical illnesses, including diabetes, alcoholism, sickle cell disease, rheumatic diseases, and immune deficiency disorders.

Symptoms of septic arthritis include fever, chills, as well as joint pain, swelling, redness, stiffness, and warmth.

Septic arthritis is diagnosed by identifying infected joint fluid. Septic arthritis is treated with antibiotics and drainage of the infected

joint fluid from the joint.


http://www.medicinenet.com/viral_infections_pictures_slideshow/article.htm

http://www.medicinenet.com/staph_infection/article.htm

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http://www.medicinenet.com/alcohol_abuse_and_alcoholism/article.htm

http://www.medicinenet.com/sickle_cell/article.htm

http://www.medicinenet.com/aches_pain_fever/article.htm

http://www.medicinenet.com/chills/symptoms.htm

http://www.medicinenet.com/joint_pain/symptoms.htm

Tubercular Arthritis


Anteroposterior view of elbow showing stage 2 lesion involving medial epicondyle only

Anteroposterior and lateral view of elbow showing stage 3A involvement (limited to coronoid)

Anteroposterior and lateral view of elbow showing stage 3B involvement (joint involvement without significant destruction)


Anteroposterior and lateral view of elbow showing stage 4 involvement (gross joint destruction with pathological fracture)

Anteroposterior (a) and lateral (b) radiographs showing bony ankylosis after anti tubercular chemotherapy



Rheumatoid arthritis: an autoimmune disease body’s immune system attacks the synovium,

or the tissue lining the joints. progressive erosion and destruction of the

cartilage and bone, leading to severe pain, stiffness, and deformity.



Primary Osteoarthritis: cartilage becomes thin over time, the bones

begin to grind against each other on rough surfaces (bone on bone).

Bone spurs or osteophytes form inside the joint.

loose bodies in the joint may cause catching symptoms as well as accelerate degeneration from mechanical wear.


Post-traumatic arthritis: One of the most common causes of arthritis Patients with a prior fracture or dislocation of

the elbow can have cartilage injury, leading to progressive deterioration of the joint.

fractures of the distal humerus, radial head fractures, and olecranon fractures. In complex injuries, there are often large cartilage defects and deformities of the elbow, leading to abnormal mechanics and rapid wear of the joint.


Olecranon bursitisInflammation behind the elbow.

The bursa sac experiences some sort of trauma or blunt force..When it receives a quick blow, it produces more fluid.

Elbow becomes inflamed and swollen.

Elbow will feel hot and be red in color.


ThanksSunday,May 1, 2016PG Teaching RRC

Healthcare

Elbow trauma & infection