Transcript
M.S. ORTHOASST. PROF. OF ORTHOPAEDICS
O.M.C/O.G.H. HYDERABAD.
Orthopaedic Rheumatologist and Interventional pain specialist
BY
DR.P.L.SRINIVAS
INJURIES AROUND THE ELBOW
MEMBER OF IORA
ELBOW DISLOCATION
EPIDEMIOLOGY
Accounts for 11% to 28% of injuries to the elbow.
Posterior dislocation is most common. Simple dislocations are those without fracture. Complex dislocations are those that occur with
an associated fracture and represent just under 50% of elbow dislocations.
Highest incidence in the 10- to 20-year old age group associated with sports injuries
MECHANISM OF INJURY
Anterior dislocation: A direct force strikes the posterior forearm with the elbow in a flexed position.
Posterir dislocation:combination of elbow hyperextension,valgus stress and forearm supination
Capsuloligamentous structures of elbow may be injured which progress from medial to lateral
CLINICAL FEATURES
• pain• gross swelling
• deformity-s shaped • tenderness• abnormal mobility• decreased range of motion
CLINICAL EVALUATION
• Elbow joint shows gross swelling and instability
• 3 point bony relationship is lost• Neurovascular examination especially vascular
compromise should be looked for before and after manipulation or reduction
ASSOCIATED INJURIES
• Associated fractures of the radial head or the coronoid process of the ulna may be present
• Uncomonly the ulnar nerve and anterior interroseus branch of the median nerve may be involved
RADIOGRAPHIC EVALUATION
• Standard anteroposterior and lateral radiographs of the elbow should be obtained.
CLASSIFICATION
Simple versus complex (associated with fracture) According to the direction of displacement of the
ulna relative to the humerus : Posterior Posterolateral Posteromedial Lateral Medial Anterior
TREATMENT PRINCIPLES
Restorationof inherent bony stability of the elbow joint
trochlear notch(coronoid and olecranon ) radial head lateral collateral ligament more imp than MCL the elbow should not redislocate before reaching
45 degrees of flexion from a fully flexed position the elbow should be able to go to 30 degrees
before substantial subluxation or dislocation
TREATMENT
Simple Elbow Dislocation Nonoperative Under sedation and adequate analgesia correction of medial or
lateral displacement followed by longitudinal traction and flexion is usually successful for posterior dislocations (parvins method /meynquigleys method
Check neurovascular status and range of motion Postreduction radiographs are essential. Postreduction management should consist of a posterior splint at 90
degrees and elevation. A hinged elbow brace through a stable arc of motion may be
indicated in cases of instability without associated fracture. Recovery of motion and strength may require 3 to 6 months
Operative
Unstable elbow The elbow cannot be held in a concentrically reduced
position redislocates before postreduction radiography Dislocates later in spite of splint immobilization We can do (1) open reduction and repair of soft tissues back to the
distal humerus (2) hinged external fixation (3) cross-pinning of the joint.
COMPLICATIONS
Loss of motion (extension): This is associated with prolonged immobilization.
Neurologic compromise: Exploration is recommended if no recovery is seen after 3
months following electromyography. Vascular injury: The brachial artery is most commonly
disrupted during injury.If, after reduction, perfusion is not reestablished, angiography
is indicated to identify the lesion, with arterial reconstruction when indicated.
COMPLICATIONS
Compartment syndrome(volkman contracture)Myositis ossificansDue to excessive manipulation and soft tissue
injury Indomethacin and local radiation therapy
prophylacticallyInstability associated with terrible triad of
elbow
FRACTURE RADIUS HEAD
INTRODUCTION
• COMMON IN ATHLETS• SIDE SWIPE INJURIES• DIRECT BLOW ON THE ELBOW WHEN
FALL OFF SKATE BOARD• HIGH ENERGY TRAUMA OCCURS IN
MOTOR CYCLE COLLISION• ANY OTHER DIRECT INJURY TO
ELBOW, HAND, WRIST, OR SHOULDER CAN AFFECT THE ELBOW TOO
SYMPTOMS
• HISTORY OF TRAUMA• PAIN• SWELLING• MOVEMENTS OF THE JOINT PAINFUL,
DECREASED• WRIST PAIN (ESSEX-LOPRESTI INJURY
MASON CLASSIFICATION
• Type I: Non-displaced 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)
CLASSIFICTION
TREATMENT GOALS
• Correction of any block to forearm rotation• Early range of elbow and forearm motion• Stability of the forearm and elbow• Limitation of the potential for ulnohumeral
and radiocapitellar arthrosis, although the latter seems uncommon
TREATMENT
Nonoperative• Most isolated fractures of the radial head can
be treated non-operatively.• Symptomatic management consists of a sling
and early range of motion, 24 to 48 hours after injury, as pain subsides.
• Aspiration of the radiocapitellar joint with or without injection of local anesthesia has been advocated by some authors for pain relief.
OPERATIVE
• Except Mason type I• ORIF with screw• KOCHER’S Approach for radial head #• Excision of radial head• MAC LAUGHLIN’S CRITERIA for immediate
excision:1. Angulation >30°2. Depression>3mm3. Involvement of head >1/3 rd
Type III: • Radial head excision is indicated with in first 24
hrs.• Excised head is replaced with prosthesis
Type IV:• Prompt reduction of the dislocation is must• Assess status of the head. If it meets the Mac
Laughlin’s criteria for excision, do it within 24 hrs.
COMPLICATIONS
• Injury to posterior interosseous nerve• Osteoarthritis• Elbow stiffness
OLECRANON FRACTURE
• Uncommon in children• Comparable to # patella• Mechanism of injury:
DIRECT: Fall on the point of elbowINDIRECT: Forcible triceps contraction
COLTON’S CLASSIFICATION (MODIFIED SCHTAZKER)
• UNDISPLACED #• DISPLACED #• AVULSION #• TRANSVERSE/OBLIQUE #• FRACTURE DISLOCATION (MONTEGGIA)• COMMINUTED #
MAYO CLASSIFICATION
Type I: Fractures are nondisplaced or minimally
displaced and are subclassified as either noncomminuted (type 1A) or comminuted (type 1B). Treatment is nonoperative.
Type II:Fractures have displacement of the proximal fragment without elbow instability; these fractures require operative treatment.– Type IIA fractures, which are noncomminuted,
can be treated by tension band wire fixation.– Type IIB fractures are comminuted and require
plate fixation
TREATMENT
• Avulsion # - TBW/LS• Transverse# - TBW/LS• Transverse# with comm.- Plate& Screws with
Bone grafting• Oblique #: Plate/LS• Communition#: Plate/TBW/Excision• Fracture Dislocation: Wire/LS/Plate• Extensile posterior approach
TBW
COMPLICATIONS
• Hardware failure occurs in 1% to 5%.• Infection occurs in 0% to 6%.• Pin migration occurs in 15%.• Ulnar neuritis occurs in 2% to 12%.• Heterotopic ossification occurs in 2% to 13%.• Nonunion occurs in 5%.• Decreased range of motion: This may
complicate up to 50% of cases
Fracture neck of radius
• Constitutes 5-10% of all elbow #s• Mech of injury fall on outstretched hand with elbow
extended and forearm supinated.• Associated with post dislocastion of elbow prox radial physis (salter haris type II)
• X ray
• Classification- steinberg et al based on initial angulation translation mild(0-30 degree, < 30% ) modetrate(30-60,<50% ) severe (>60,>50%)
• Treatment - conservative for
< 30 degree
-percutaneus reduction technique
with k wires or Lag
screw
-ORIF with k wires/ cc screws severe angulation
failed closed /percutaneus
methods
• Complications depends on initial angulation -decreased range of motion -avascular necrosis -premature physial closure -cubitus valgus
THANK YOU
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