Fractures around Fractures around elbow elbow

Dr. Waleed Faris Al- RawiDr. Waleed Faris Al- Rawi

Supracondylar fractureSupracondylar fracture

These are among the commonest These are among the commonest fractures in children, may be the fractures in children, may be the most worrisome of all pediatric most worrisome of all pediatric upper extremity fractures because upper extremity fractures because their association with their association with neurovascualar injury.. The distal neurovascualar injury.. The distal fragment displaced either fragment displaced either posteriorly or anteriorlyposteriorly or anteriorly

Mechanism of injuryMechanism of injuryPosterior angulation or displacement Posterior angulation or displacement

occur in 95% of all cases suggest hyper occur in 95% of all cases suggest hyper extension injury , usually due to extension injury , usually due to outstretched hand, The distal fragment is outstretched hand, The distal fragment is pushed backwards and ( because the pushed backwards and ( because the forearm usually in pronation ) twisted forearm usually in pronation ) twisted inward. The jagged end of the proximal inward. The jagged end of the proximal fragment pocks into the soft tissues fragment pocks into the soft tissues anteriorly, some times injuring the anteriorly, some times injuring the brachial artery or median nervebrachial artery or median nerve..

Anterior displacement is rare , it is Anterior displacement is rare , it is thought to be due to direct violence thought to be due to direct violence e.g a full on the point of the elbow e.g a full on the point of the elbow with joint in flexionwith joint in flexion..

ClassificationClassification11 - -Type 1 is undisplaced fractureType 1 is undisplaced fracture 22 - -Type 2 is an angulated fracture Type 2 is an angulated fracture

with the posterior cortex still in with the posterior cortex still in continuity, 2A being less sever and continuity, 2A being less sever and merely angulated and 2B being more merely angulated and 2B being more sever and both angulated and sever and both angulated and malrotatedmalrotated..

33 - -Type 3 is a completely displaced Type 3 is a completely displaced fracturefracture..

Clinical featuresClinical featuresFollowing a fall there is pain and the Following a fall there is pain and the

elbow is swollen with a posteriorly elbow is swollen with a posteriorly displaced fracture the S-shape deformity displaced fracture the S-shape deformity of the elbow is usually obvious and the of the elbow is usually obvious and the bony landmarks are abnormal. It is bony landmarks are abnormal. It is essential to feel the pulse and check the essential to feel the pulse and check the capillary return, passive extension of the capillary return, passive extension of the flexor muscles should be pain free. The flexor muscles should be pain free. The wrist and the hand should be examined wrist and the hand should be examined for evidence of nerve injuryfor evidence of nerve injury..

X-RayX-RayThe fracture is seen most clearly in The fracture is seen most clearly in

the lateral view. In an undisplaced the lateral view. In an undisplaced fracture the fat pad sign should raise fracture the fat pad sign should raise suspicions, these is triangular suspicions, these is triangular lucency in front of distal humerus lucency in front of distal humerus due to the fat pad being pushed due to the fat pad being pushed forward by a haematomaforward by a haematoma . .

In the common posteriorly displaced In the common posteriorly displaced fracture the fracture line runs fracture the fracture line runs obliquely downward and forward obliquely downward and forward and the distal fragment is tilted and the distal fragment is tilted backward. In the anteriorly backward. In the anteriorly displaced fracture the cracks runs displaced fracture the cracks runs downward and backward and the downward and backward and the fragment is tilted forwardsfragment is tilted forwards . .

The anteroposterior view is painful The anteroposterior view is painful and may be postponed until the child and may be postponed until the child has been anesthetized, it may show has been anesthetized, it may show that the distal fragment is shifted or that the distal fragment is shifted or tilted sideways. Measurement of tilted sideways. Measurement of Baumanns angle is useful in Baumanns angle is useful in assessing the degree of medial assessing the degree of medial angulation before and after angulation before and after reductionreduction..

TreatmentTreatmentThe goal of management of The goal of management of

supracondylar fracture is to restore supracondylar fracture is to restore and maintain anatomic or near and maintain anatomic or near anatomic aligment with a minimum anatomic aligment with a minimum of complicationsof complications . .

TreatmentTreatmentType 1; undisplaced fractureType 1; undisplaced fracture

The elbow is immobilized at 90 The elbow is immobilized at 90 degree and neutral rotation in cast degree and neutral rotation in cast and the arm is supported by a sling. and the arm is supported by a sling. It is essential to obtain an x-ray 5-7 It is essential to obtain an x-ray 5-7 days later to check that there has days later to check that there has been no displacement. The cast is been no displacement. The cast is retained for 3 weeks then movement retained for 3 weeks then movement is allowedis allowed..

TreatmentTreatmentType 2 Posteriorly angulated fracture- Type 2 Posteriorly angulated fracture-

mildmildIn these cases swelling is usually not In these cases swelling is usually not

severe and the risk of vascular injury is severe and the risk of vascular injury is low. If the posterior cortices are in low. If the posterior cortices are in continuity, the fracture can be reduced continuity, the fracture can be reduced ander general anesthesia and during ander general anesthesia and during reduction pulse Is felled and check the reduction pulse Is felled and check the capillary return and if distal circulation is capillary return and if distal circulation is suspected immediately relax elbow suspected immediately relax elbow flexion until it improvesflexion until it improves..

Following reduction the arm held in collar and Following reduction the arm held in collar and cuff and the circulation should be checked cuff and the circulation should be checked repeatedly during the first 24 hoursrepeatedly during the first 24 hours..

An x-ray is taken after 3-5 days to confirm An x-ray is taken after 3-5 days to confirm that the fracture has not slipped. The splint is that the fracture has not slipped. The splint is retained for 3 weeks then movement is retained for 3 weeks then movement is startedstarted..

If the acutely flexed position cannot be If the acutely flexed position cannot be maintained without disturbing the circulation maintained without disturbing the circulation or if the reduction is unstable, the fracture or if the reduction is unstable, the fracture should be fixed with percutaneous crossed should be fixed with percutaneous crossed Kirschner wiresKirschner wires..

Type 2B and 3 angulated and malrotated or Type 2B and 3 angulated and malrotated or posteriorly displacedposteriorly displaced

These are usually associated with severe These are usually associated with severe swelling, are difficult to reduced and are often swelling, are difficult to reduced and are often unstable and there is a considerable risk of unstable and there is a considerable risk of neurovascular injury or circulatory compromised neurovascular injury or circulatory compromised due swelling. The fracture should be reduced due swelling. The fracture should be reduced under general anaesthesia as soon as possible under general anaesthesia as soon as possible and then held with percutaneous crossed and then held with percutaneous crossed Kirschnner wires and wires should be smooth to Kirschnner wires and wires should be smooth to prevent physeal injury and great care should be prevent physeal injury and great care should be taken not to injure ulnar and radial nervestaken not to injure ulnar and radial nerves..

Open reductionOpen reduction This is some times necessary for (1) This is some times necessary for (1)

a fracture which simply cannot be a fracture which simply cannot be reduced closed (2) an open fracture reduced closed (2) an open fracture or (3) a fracture associated with or (3) a fracture associated with vascular damagevascular damage..

ComplicationsComplicationsEarlyEarly

11 - -Vascular injury; The supracondylar fracture Vascular injury; The supracondylar fracture associated with injury to brachial artery which associated with injury to brachial artery which befor introduction of percutaneous pinning was befor introduction of percutaneous pinning was reported as occurring in over 5% which was reported as occurring in over 5% which was dropped nowadays to less than 1%. Peripheral dropped nowadays to less than 1%. Peripheral ischemia may be immediate and severe or the ischemia may be immediate and severe or the pulse may fail to return after reduction. More pulse may fail to return after reduction. More commonly the injury is complicated by forearm commonly the injury is complicated by forearm oedema and a mounting compartment syndrome oedema and a mounting compartment syndrome which leads to necrosis of the muscles and which leads to necrosis of the muscles and nerves without causing peripheral gangrenenerves without causing peripheral gangrene . .

Pain plus one positive sign ( pain on passive Pain plus one positive sign ( pain on passive extension of the fingers, a tense and tender extension of the fingers, a tense and tender forearm, an absent pulse, blunted sensation forearm, an absent pulse, blunted sensation 0r reduced capillary return on pressing the 0r reduced capillary return on pressing the finger pulp ) demands urgent action. Flexed finger pulp ) demands urgent action. Flexed elbow must be extended and all dressing elbow must be extended and all dressing removed. If the circulation does not improve removed. If the circulation does not improve angiography ( on the operating table if it is angiography ( on the operating table if it is saved time ) is carried out, the vessel repaired saved time ) is carried out, the vessel repaired or grafted and a forearm fasciotomy or grafted and a forearm fasciotomy performed. If angiography is not available performed. If angiography is not available Doppler imaging should be used. In extreme Doppler imaging should be used. In extreme cases operative explorations would be cases operative explorations would be justified on clinical criteria alonejustified on clinical criteria alone..

22 - -Nerve injuryNerve injuryThe median nerve particularly the anterior The median nerve particularly the anterior

interosseous branch may be injured. Loss interosseous branch may be injured. Loss of function is usually temporary and of function is usually temporary and recovery can be expected in 6-8 weeksrecovery can be expected in 6-8 weeks . .

The ulnar nerve may be damage by The ulnar nerve may be damage by careless pinning. If the injury is careless pinning. If the injury is recognized and the pin removed recovery recognized and the pin removed recovery will usually followwill usually follow..

LateLate11 - -Malunion; it is common complication, Malunion; it is common complication,

However backwards or sideways shifts However backwards or sideways shifts are gradually smoothed out by modeling are gradually smoothed out by modeling during growth and they seldom give rise during growth and they seldom give rise to visible deformity of the elbow. to visible deformity of the elbow. Forwards or backwards tilt may limit Forwards or backwards tilt may limit flexion or extension but consequent flexion or extension but consequent disability is slightdisability is slight..

Uncorrected sideway tilt (angulations) and Uncorrected sideway tilt (angulations) and rotation are much more important and may rotation are much more important and may lead to varus (or rarely valgus) deformity of lead to varus (or rarely valgus) deformity of the elbow, this is permanent and will not the elbow, this is permanent and will not improve with growth. The fracture is improve with growth. The fracture is extraphyseal and so physeal damage should extraphyseal and so physeal damage should not be blamed with deformity, usually it is not be blamed with deformity, usually it is faulty reduction which is responsible. Cubitus faulty reduction which is responsible. Cubitus is disfiguring and cubitus valgus may cause is disfiguring and cubitus valgus may cause late ulnar palsy. If deformity is marked it will late ulnar palsy. If deformity is marked it will need correction by supracondylar osteotomyneed correction by supracondylar osteotomy..

22 - -Elbow stiffness and myositis ossificansElbow stiffness and myositis ossificansStiffness is a common complication Stiffness is a common complication

following elbow injury. Extension is following elbow injury. Extension is particular may take months to return. It particular may take months to return. It must not be hurried. Passive movement must not be hurried. Passive movement (which includes carrying weights ) or (which includes carrying weights ) or forced movement is prohibited, this will forced movement is prohibited, this will only make matters worse and may only make matters worse and may contribute to the development of contribute to the development of myositis ossificansmyositis ossificans . .

Fracture lateral condyleFracture lateral condyle

The lateral condyle begin to ossify The lateral condyle begin to ossify during first year of life and fuse with during first year of life and fuse with the shaft at 12-16 years. Between the shaft at 12-16 years. Between these ages it may be sheared off or these ages it may be sheared off or avulsed by forceful tractionavulsed by forceful traction..

Mechanism of injury and Mechanism of injury and pathologypathology

The child falls on the hand with the elbow The child falls on the hand with the elbow extended and forced in to varus. A large extended and forced in to varus. A large fragment which includes the lateral condyle fragment which includes the lateral condyle breaks off and is pulled by the attached wrist breaks off and is pulled by the attached wrist extensors. In sever cases the elbow dislocate extensors. In sever cases the elbow dislocate posterolaterally, the condyle is capsized by posterolaterally, the condyle is capsized by muscle pull and remains capsized while the muscle pull and remains capsized while the elbow reduced spontaneouslyelbow reduced spontaneously . .

The fracture is important for two reasonsThe fracture is important for two reasonsIt may damage the growth plateIt may damage the growth plate

It always involves the jointIt always involves the joint

Clinical featuresClinical features The elbow is swollen and deformed. The elbow is swollen and deformed.

There is tenderness over the lateral There is tenderness over the lateral condyle and passive flexion of the condyle and passive flexion of the wrist may be painfullwrist may be painfull..

X-RayX-RayTwo types of fractures are recognizedTwo types of fractures are recognized

A fracture lateral to the trochlea, the A fracture lateral to the trochlea, the humeroulnar joint not involved and is humeroulnar joint not involved and is stablestable

A fracture through the middle of A fracture through the middle of trochlea, this injury is more common trochlea, this injury is more common and elbow unstable and it may and elbow unstable and it may dislocatedislocate..

TreatmentTreatmentIf there is no or minimal If there is no or minimal

displacement the arm can be displacement the arm can be splinted in a back slab with the splinted in a back slab with the elbow flexed 90 degrees and wrist elbow flexed 90 degrees and wrist extendedextended

A displaced fracture i.e with a gap of A displaced fracture i.e with a gap of more than 2 mm required accurate more than 2 mm required accurate reduction and internal fixationreduction and internal fixation..

ComplicationsComplicationsNon union and mal unionNon union and mal union

Recurrent dislocationRecurrent dislocation

Fractures of the medial Fractures of the medial condylecondyle

Mechanism of injuryMechanism of injuryThe injury is usually caused by fall The injury is usually caused by fall

from height involving either a direct from height involving either a direct blow to the point of the elbow or a blow to the point of the elbow or a landing on the out stretched hand landing on the out stretched hand with the elbow forced in to valguswith the elbow forced in to valgus..

Clinical featuresClinical featuresThis is an intra articular fracture This is an intra articular fracture

resulting in considerable pain and resulting in considerable pain and swellingswelling . .

TreatmentTreatmentUndisplaced fracture treated by Undisplaced fracture treated by

splintage, x-rays are repeated until splintage, x-rays are repeated until fracture has healdfracture has heald..

Displaced fracture are treated either Displaced fracture are treated either by closed reduction and by closed reduction and percutaneous pinning or by open percutaneous pinning or by open reduction and fixation with pinsreduction and fixation with pins..

ComplicationsComplications EarlyEarly

Ulnar nerve damageUlnar nerve damage LateLate

Stiffness of elbow jointStiffness of elbow jointLate ulnar nerve palsyLate ulnar nerve palsy

Fracture neck of radiusFracture neck of radius Mechanism of injury and pathologyMechanism of injury and pathology

A fall on the outstretched hand A fall on the outstretched hand forces the elbow in to valgus and forces the elbow in to valgus and pushes the radial head against the pushes the radial head against the capitulum. In the children the bone capitulum. In the children the bone fractures through the neck of the fractures through the neck of the radius, in adult the injury is more radius, in adult the injury is more likely to fracture the radial headlikely to fracture the radial head..

Clinical featuresClinical featuresFollowing a fall the child complains Following a fall the child complains

of pain in the elbow. There may be of pain in the elbow. There may be localized tenderness over the radial localized tenderness over the radial head and pain on rotating forearmhead and pain on rotating forearm..

X-RayX-RayThe fracture line is transverse. It The fracture line is transverse. It

either situated immediately distal to either situated immediately distal to the physis or there is true separation the physis or there is true separation of the epiphysis with a triangular of the epiphysis with a triangular fragment of shaft ( salter-Harris II fragment of shaft ( salter-Harris II injury )injury ) . .

TreatmentTreatmentIn children up to 30 degrees of radial In children up to 30 degrees of radial

head tilt and up to 3 mm of transverse head tilt and up to 3 mm of transverse displacement are acceptable. The arm displacement are acceptable. The arm rested in coller and cuff and exercises rested in coller and cuff and exercises are started after a weekare started after a week..

Displacement more than 30 degrees Displacement more than 30 degrees requires reduction. If closed reduction requires reduction. If closed reduction fails open reduction are performedfails open reduction are performed..

Pulled elbowPulled elbowIn young children the elbow may be In young children the elbow may be

injured by pulling on the arm usually with injured by pulling on the arm usually with the forearm pronated. It is some times the forearm pronated. It is some times called sublaxation of the radial headcalled sublaxation of the radial head . .

A child aged 2-3 years is brought with a A child aged 2-3 years is brought with a painful dangling arm with the forearm painful dangling arm with the forearm held in pronation and extentionheld in pronation and extention..

A dramatic cure is achieved by forcefully A dramatic cure is achieved by forcefully supinating and then flexing the elbowsupinating and then flexing the elbow..

Fractured head of the Fractured head of the radiusradius

Mechanism of injuryMechanism of injuryA fall on the out stretched hand with A fall on the out stretched hand with

the elbow extended and the forearm the elbow extended and the forearm pronated causes impaction of the pronated causes impaction of the radial head against capitulum.The radial head against capitulum.The radial head is also sometimes radial head is also sometimes fractured during elbow dislocationfractured during elbow dislocation..

Clinical featuresClinical features Tenderness on pressure over the Tenderness on pressure over the

radial head and pain on pronation radial head and pain on pronation and supination should suggest the and supination should suggest the diagnosisdiagnosis..

X-RayX-Ray33 types of of fractures are identifiedtypes of of fractures are identified

Type I ; A vertical split in the radial Type I ; A vertical split in the radial headhead..

Type II; A single fragment of the Type II; A single fragment of the lateral portion of the head broken off lateral portion of the head broken off and displaced distallyand displaced distally..

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

TreatmentTreatmentAn undisplaced type I; The arm held in a An undisplaced type I; The arm held in a

collar and cuff for 3 weekscollar and cuff for 3 weeks..Type II; if the fragment is displaced it Type II; if the fragment is displaced it

should be reduced and held with a small should be reduced and held with a small screwscrew..

A comminuted fracture type III; excision of A comminuted fracture type III; excision of the radial head. However if there is the radial head. However if there is disruption of distal radioulnar the excised disruption of distal radioulnar the excised head must replaced by silicone or metal head must replaced by silicone or metal prosthesisprosthesis..

ComplicationsComplicationsJoint stiffnessJoint stiffness

Myositis ossificansMyositis ossificans Recurrent instability of the elbow Recurrent instability of the elbow

jointjoint

Fractures of the Fractures of the olecranonolecranon

Two types of injury are seenTwo types of injury are seen ) ( ) (A comminuted fracture which is A comminuted fracture which is

due to direct blow or afall on the due to direct blow or afall on the elbowelbow..

) ( ) (a clean transverse break due to a clean transverse break due to traction when the patient falls onto traction when the patient falls onto hand while triceps muscle is hand while triceps muscle is contractedcontracted

Clinical featuresClinical featuresA bruise over the elbow suggest A bruise over the elbow suggest

comminuted fracture and triceps comminuted fracture and triceps intact and the elbow can be intact and the elbow can be extendedextended..

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

TreatmentTreatmentA comminuted fracture with triceps A comminuted fracture with triceps

intact treated in arm sling for a week intact treated in arm sling for a week then patient start movementthen patient start movement..

An undisplaced fracture treated An undisplaced fracture treated conservatively by a cast with elbow conservatively by a cast with elbow flexed 60 degrees for 2-3 weeksflexed 60 degrees for 2-3 weeks..

Displaced fracture treated by open Displaced fracture treated by open reduction and internal fixation by reduction and internal fixation by tension band wiringtension band wiring..

ComplicationsComplications )( )(Stiffness of elbow jointStiffness of elbow joint

)()(Non-unionNon-union )( )(osteoarthritisosteoarthritis

Dislocation of the elbowDislocation of the elbowDislocation of the ulnohumeral joint Dislocation of the ulnohumeral joint

is fairly common more in adult than is fairly common more in adult than childrenchildren

Mechanism of injury and Mechanism of injury and pathologypathology

The cause of posterior dislocation is usually a fall The cause of posterior dislocation is usually a fall on out stretched hand with the elbow in on out stretched hand with the elbow in extension. Disruption of capsuloligamentous extension. Disruption of capsuloligamentous structure alone can result in posterior or structure alone can result in posterior or posterolateral dislocationposterolateral dislocation..

Whoever provided there is no fractures Whoever provided there is no fractures reduction will usually stable and recurrent reduction will usually stable and recurrent dislocation unlikely. The combination of dislocation unlikely. The combination of ligamentous disruption and fracture of radial ligamentous disruption and fracture of radial head, coronoid process or olecranon fracture or head, coronoid process or olecranon fracture or several fractures will render the joint unstable several fractures will render the joint unstable and unless the fractures are reduced and fixed and unless the fractures are reduced and fixed liable to redislocateliable to redislocate..

Clinical featuresClinical featuresThe patient support his or her The patient support his or her

forearm with the elbow in slight forearm with the elbow in slight flexion. Unless swelling is sever the flexion. Unless swelling is sever the deformity is obviosdeformity is obvios..

The bony landmarks ( epicondyles The bony landmarks ( epicondyles and olecranon ) may be palpable and and olecranon ) may be palpable and abnormally placedabnormally placed..

TreatmentTreatmentThe surgeon pulls on the forearm The surgeon pulls on the forearm

while the elbow is slightly flexed, while the elbow is slightly flexed, then the elbow is further flexed while then the elbow is further flexed while the olecranon pushed forward with the olecranon pushed forward with the thumb, then do complete flexion the thumb, then do complete flexion of the elbow jointof the elbow joint..

After reduction elbow flexed above 90 After reduction elbow flexed above 90 degrees by collar and cuff for 3 weeksdegrees by collar and cuff for 3 weeks

ComplicationsComplications )( )(EarlyEarly

Vascular injury I.e Brachial arteryVascular injury I.e Brachial arteryNerve injury i.e Ulnar nerve or median Nerve injury i.e Ulnar nerve or median

nervenerve.. )( )(LateLate

Stiffness of elbow jointStiffness of elbow joint..Heterotopic ossificationHeterotopic ossification..

Unreduced dislocationUnreduced dislocationRecurrent dislocationRecurrent dislocation..

OsteoarthritisOsteoarthritis

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