ELBOW AND FOREARM FRACTURES FRACTURESPRESENTED BY

MWADZIWANA LOUIS LAW

Elbow joint Anatomy

Fractures of the distal humerus

In adults they are associated with high-energy injuries.

In children - falls with an outstretched arm The AO-ASIF Group have defined three types of

distal humeral fracture: 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 of comminution.

Supracondylar fractures type A

rare in adults. Usually they are displaced and unstable In 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 stable K-wire fixation is not strong enough to permit early

mobilization.

Types B and C intra articular fractures

high-energy FRACTURES AND JOINT INJURIES injuries 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. Pulselessness

ii. Pallor

iii.Pain

iv.Paresthesia

v. 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.

Reduction of a supracondylar fracture

Txt Displaced type B and C

ORIF K wire can be used unicondylar fracture without comminution can then be

fixed with screws; if the fragment is large, a contoured plate is added to prevent re-displacement.

Plates with locking screws 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 treatments Elbow replacement The ‘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 injury Nerve injury median nerve Volkmann’s ischemic contracture Malunion leading to gunstock deformity Myositis ossificans Stiffness

FRACTURED CAPITULUM rare articular fracture Mainly occurs in adults elbow is tender and flexion is grossly restricted Mechanism 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.

Can You See The Capitulum

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 screws Movements are commenced as soon as discomfort

permits

Fractured head of the Radius Common in adults A fall on the outstretched hand with the elbow

extended and the forearm pronated Impaction of the radial head against the capitulum

causes the radial head to split or brake Clinical features - tenderness on pressure over the

radial head and pain on pronation and supination

X-rays Three types of fracture are identified and classified by Mason as:

i. Type I An undisplaced vertical split in the radial head

ii. Type II A displaced single fragment of the head

iii. Type III The head broken into several fragments (comminuted).

Treatment

An undisplaced split (Type I) Aspirating the haematoma and injecting local

anaesthetic. The arm is held in a collar and cuff for 3 weeks; active

flexion, extension and rotation are encouraged. The prognosis for this injury is very good

A single large fragment (Type II) reduced and held with one or two small headless screws.

Treatment

A comminuted fracture (Type III).

Always assess for an associated soft tissue injury:

i. Rupture of the medial collateral ligament

ii. Rupture of the interosseous membrane

iii. Combined fractures of the radial head and coronoid process plus dislocation of the elbow ‘the terrible triad’.

If any of these is present, excision of the radial head is contra-indicated; this may lead to intractable instability of the elbow or forearm.

The head must be reconstructed with small headless screws or replaced with a metal spacer.

A medial collateral rupture, if unstable after replacing or fixing the radial head, should be repaired.

Complications

Joint stiffness both the elbow and the radioulnar joints. Delayed union Stiffness Myositis ossificans Recurrent instability of the elbow joint

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 elbow

ii. 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 fractures

ii. Undisplaced fractures. Subluxation or dislocation of the ulno-humeral joint in

severe injuries The fracture always enters the elbow joint and therefore

damages the articular cartilage.

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.

Treatment

A 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.

Treatment

Displaced comminuted fractures need a plate and often bone graft.

Following operation, early mobilization should be encouraged.

Main Complications

Stiffness Non-union due to inadequate reduction and

fixation. Ulnar nerve symptoms can develop. Osteoarthritis

Radius and Ulnar bones

Fractures of the radius and the ulna

Common both in children and adults Mechanism of injury

Twisting forces produces a spiral fracture with the bones broken at different levels.

An angulating force causes a transverse fracture of both bones at the same level.

A direct blow causes a transverse fracture of just one bone, usually the ulna.

Additional rotation deformity may be produced by the pull of muscles attached to the radius

Clinical features

Obvious fractures due to deformity Check for the five P’s

i. Pulselessness

ii. Pallor

iii.Pain

iv.Paresthesia

v. Paralysis

X-ray

Both bones are broken In children, the fracture is often incomplete

(greenstick) and only angulated. In adults, displacement may occur in any

direction – shift, overlap, tilt or twist. In low-energy injuries, the fracture tends to be

transverse or oblique; in high-energy injuries it is comminuted or segmental

X-ray images of the forearm

Treatment in children

Closed treatment because the tough periosteum tends to guide and then control the reduction.

The fragments are held in a full-length cast, from axilla to metacarpal shafts (to control rotation).

For 6-8weeks. The cast is applied with the elbow at 90 degrees. If the fracture is proximal to pronator teres, the

forearm is supinated; if it is distal to pronator teres, then the forearm is held in neutral.

Treatment in children continued

If the conservative method fails ORIF is done Fixation with intramedullary rods is preferred,

avoid injury to the growth plates. Alternatively, a plate or K-wire fixation can be

used.

Childhood fractures usually remodel well, but not if there is any rotational deformity or an angular deformity

Treatment in adults

Open reduction and internal fixation

The fragments are held by inter fragmentary compression with plates and screws.

Bone grafting is advisable if there is comminution.

The deep fascia is left open to prevent compartment syndrome, only the skin is sutured.

External fixation if it is a compound fracture

Plate and screws

Adult treatment

After the operation the arm is kept elevated until the swelling subsides, and during this period active exercises of the hand are encouraged.

If the fracture is stable Early ROM exercises are commenced but

lifting and sports are avoided. It takes 8–12 weeks for the bones to unite. With comminuted fractures or unreliable

patients, immobilization in plaster is safer.

Complications

Early complications Nerve injuries Vascular injury Compartment syndrome

Late complications Delayed union and nonunion Malunion and cross union Complications of plate removal

Isolated fracture of the forearm

Uncommon Caused by direct trauma E.g. when protecting the face

Clinical features X-ray showing fractures, ulnar fracture

difficult to see Swelling Deformity Dislocations on the distal and proximal joints

TreatmentIsolated fracture of the ulna

Undisplaced fracture Elbow flexed full arm cast or forearm brace. 8 weeks before full activity can be resumed.

Displaced fractures ORIF to prevent rotational elements Advantage allow earlier activity and avoids

the risk of displacement or non-union.

TreatmentIsolated fracture of the radius

Radius fractures are prone to rotary displacement;

To achieve reduction in children the forearm needs to be

i. supinated for upper third fractures,

ii. neutral for middle third fractures

iii.pronated for lower third fractures.

If the reduction fails; then internal fixation with a compression plate and screws in adults, and preferably intramedullary rods in children.

Isolated fractures of the forearm

Monteggia Fracture

Fracture of the shaft of the ulna associated with dislocation of the proximal radio-ulnar joint and the radiocapitellar joint.

In children, the ulnar injury may be an incomplete fracture (greenstick or plastic deformation of the shaft)

Mechanism of injury

Usually the cause is a fall on the hand; if at the moment of impact the body is twisting, its momentum may forcibly pronate the forearm.

The radial head usually dislocates forwards

and the upper third of the ulna fractures and bows forwards.

Sometimes the causal force is hyperextension

Clinical features

ulnar deformity is usually obvious the dislocated head of radius is masked by

swelling. A useful clue is pain and tenderness on the lateral side of the elbow.

The wrist and hand should be examined for signs of injury to the radial nerve.

X-RAYS

The head of the radius is dislocated forwards, and there is a fracture of the upper third of the ulna with forward bowing.

Backward or lateral bowing of the ulna is likely to be associated with, respectively,

Posterior or lateral displacement of the radial head.

Trans-olecranon fractures, also, are often associated with radial head dislocation.

Monteggia Fracture X-ray

Treatment

Aim is to restore the length of the fractured ulna

The ulnar fracture must be accurately reduced, with the bone restored to full length, and then fixed with a plate and screws.

The radial head usually reduces once the ulna has been fixed.

Stability must be tested through a full ROM. If the elbow is completely stable, then flexion–

extension and rotation can be started after surgery. If there is doubt, then the arm should be immobilized

in plaster with the elbow flexed for 6 weeks

TREATED MONTEGGIA FRACTURE

Ulnar Fracture

Hume fracture - a fracture of the olecranon with an associated anterior dislocation of the radial head

GALEAZZI FRACTURE-DISLOCATIONOF THE RADIUS

Fractured radius with dislocation of the distal radioulnar joint

More common than the Monteggia fracture Mechanism of injury

Fall on an outstretched hand; probably with a rotation force.

The radius fractures in its lower third and the inferior radio-ulnar joint subluxates or dislocates.

Clinical features

Prominence or tenderness over the lower end of the ulna.

It may be possible to demonstrate the instability of the radio-ulnar joint by rotating the wrist.

Test for an ulnar nerve lesion X-ray

A transverse or short oblique fracture is seen in the lower third of the radius, with angulation or overlap.

The distal radio-ulnar joint is subluxated or dislocated.

Treatment

restore the length of the fractured bone Conservative method is usually successful in

children In adults ORIF and compression screws of the

radius X-ray to verify that the distal radio-ulnar joint

is reduced

Reduced Galeazzi Fracture

Complications

Malunion because the distal fragment has no longitudinal support

Cross union Compartment syndrome

Radius fracture

Essex-Lopresti fracture - a fracture of the radial head with concomitant dislocation of the distal radio-ulnar joint with disruption of the interosseous membrane.

Physiotherapy treatment

The physiotherapist carries out an assessment of the patient and then formulates a plan of treatment.

Aims of physiotherapy treatment To reduce any swelling. To regain full range of joint movement. To regain full muscle power. To re-educate full function. Maintain Soft Tissue and Joint Mobility Maintain Integrity and Function of Related Areas

Physiotherapy management

soft tissue massage joint mobilization electrotherapy (e.g. ultrasound) taping or bracing ice or heat treatment the use of a protective gear like splints exercises to improve strength, flexibility and balance hydrotherapy Patient education activity modification eg ADL’s a graduated return to activity plan

Physiotherapy treatment

Reduce Effects of Inflammation or Synovial Effusion and Protect the Area

Immobilization in a sling provides rest to the part, weigh with complete immobilization

Frequent periods of controlled movement within a pain-free range should be performed.

Salter Harris Classification

References

Apley’s System of Orthopedics and Fractures

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