Dr. pl srinivas ug class 1

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