fracture & dislocation around the elbow

Fracture &

dislocation

around the

elbow

Anatomy of the Elbow

Bone of elbow

1-humerus

2-radus

3- ulna

Bony part

It is synovial hinge joint

between

A- the trochlea and the

capitulum of the

humerous AND

B- the trochlear notch of

the ulna and the upper

surface of the head of

radius

Elbow joint (ligament)

1- radial collateral lig.

2- anular lig. Of radius

3- ulnar collateral lig.

4- transverse lig.

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ulnar ligament called also the

medial collateral ligament. It

prevent abduction تباعدof elbow

joint. It cosists of 3 bands:

Anterior, posterior, Transverse.

radial ligament called also

The lateral collateral ligament.it

prevent adduction of elbow

Muscles

a

Artery &Nerve

Median n

radial n

ulnar n

movement in the region of

the elbow

Two sits of movements occur in the region of elbow

A/flexion and extension . at the elbow joint

B/pronation and supination . At Superior radio-ulnar joint

Flexors muscle 1/brachialis 2/biceps 3/brachio-radialis 4/flexore of forearm

Extensors muscle 1/triceps 2/anconeus

Pronator 1/pronator teres 2/pronator quadratus

Supinators

1/biceps 2/supinator.

Movement of elbow

fracture Hx & Ex

Clinical manifistation in Median

nerve injury

Wrist drop in case of radial

nerve injury

fructures OF THE ELBOW

fractures of distal end of the humerus

fracture of proximal end of radius

fracture of the proximal of the ulna

Avulsion fracture

◦ Avulsion of the epiphysis of the medial

epicondyle

◦ Avulsion fracture of the epiphysis of the

lateral epicondyle

Fractures of distal humerus Mechanism of injury: -high energy except in

osteoporotic. -falling on flexed elbow > 90 degree.

classification [ A O ] : divided into:

- type A: extraarticular

- typeB: intraarticular unicondylar frct .[one condyle sheared off and the still in contact with the shaft.

- typeC: intraarticular bicondylar [no one in contact with the shaft] . has subgroups:- simpleTorY

- extraarticular comminution

- intraarticular comminution

Fracture of the distal end of

the humerus

Classification :1- Supracondylar.

2- Condylar.

3- Intercondylar.

1- Supracondylar fractures

The commonest fracture in

children

boy are injured more than girls and

more of patient are under 10 years

Supracondylar fracture

Tow type of supra condylar fracture

according to the direction of distalthe

fragment (direction of displacement)

A/supracodylar fracture with posterior

displacement of distal fragment *extension type* account 95% of case

cause by fall on the hand with elbow bent

Supracondyle fracture with

posterior displacement

b/supracondylar fracture with anterior

displacement of distal fragment

flexion type it account 5% of cases it

cause by a fall on hand with elbow

extended

Classification according to

severity of degree of wilkintType 1- undisplaced fracture

Type 2- Green stick fracture with angulation

A- less sever and angulated

B- more sever and both angulated and

Malrotated.

Type 3- completely displaced fracture

DIAGNOSISFollowing the fall child

complain of pain in

the elbow and

tenderness in the

distal humerus and

swelling and deformity

but the olecranion and

medial , lateral

epicondyles preserve

their normal

equilateral triangular

relationship

X- ray :AP &Lat

veiw

It is essential to examine

fore neurovascular

damage .the brachial

artery may be affected so

pulse examination is

essential also nerve

injury commonly median

nerve

management1*supracodylar fracture with posterior

displacement –our aim is to secure reduction with no angulation or rotation . the conservative method is the method of choice

A*reduction 1/the surgeon exert traction on the injured limb with elbow slightly flexed then flexed the elbow to 80with while pushing forward the lower fragment with his thump.*the radial pulse must be checked if the pulse weak or disappear the degree of elbow flexion is reduced until the pulse returns .

B*immobilization by simple collar and cuffis applied . C*rehabilitation immobilization should be continue for 3week after that the child allowed to take the hand out of the cuff for activities such as washing ,dressing and writing. Elbow flexion is encouraged but not extension .operative method indicated if there is vascular damage , the fracture may fixed using kireschner wire ..

2*supracondylar fracture with

anterior displacement . this usually

reduced by pulling the arm with the

elbow fully extended . immobilization

is achieved by a plaster slab with the

elbow extended for3weeks following

by active gradually elbow flexion

Internal fixation of supracondylar

fracture

Complication of supracondylar

fractures 1 - early complications a/vascular injury : which if untreated will

lead to volkmanns ischaemia b/nerve injury : the median , ulnar and

radial nerve are some time injured but usually recover spontaneously .the most common affected is the median nerve..

2 - late complications a/myositis ossificans . b/stiffness of

joint c/malunion . d/late ulnar palsy.

Dislocation of the elbowDislocation of ulnohumeral joint in adult more than in children , radioulnar complex is displaced posteriorly or posterolateral often together with fractures.

Mechanism of injury 1

Posterior dislocation *the common type

1-because fall on the out striated hand with the elbow extend .2-disruptur of capsuloligamentous structure alone it also lead to posteriolateraly dislocation.*dislocation without recurrent dislocation . not the combination of fractures.

Posterior dislocation Lateral dislocation

If there is tissue damage may combined with surrounding nerve and vesicular damage

sid-swip injury / in car drivers elbow the result forward dislocation with fracture of bone around elbow , soft tissue damage usually sever

Clinical features slight flex hand , swelling , deformity , bony land mark in abnormal place , pain ,the hand should be examine for neurovesicular damage

TreatmentAnatomical reduction is essential should be soon as possible . the majority of cases are treated conservatively . surgical intervention may be indicated fore the associated fractures . a-reductionby traction on the forearm in the position in which it lies ,in order to over com biceps and triceps shorting , at the same time the olecranon is pushed forward by thump whilst the elbow is slowly flexed . the stability is then checked by gently moving the elbow through its normal range .b-immobilization . this can be achieved by collar and cuff with or without a posterior slab for 3 week with elbow at 90 flexed .c-rehabilitation Shoulder and finger exercise should command at once .while genteel active . elbow exercise should common after on week.

Anterior dislocation

Complications vascular injury of brachial artery may occur but

with a lesser frequency than in cases of supracondylar fracture .

nerve injury . the medial ulnar nerve may be affected .c/myositis ossification ,which is more common if passive exercise is inflicted on the patient.

Recurrent of the dislocation may occur if the bony , ligamentous, and muscular support structure are disrupted sufficeintly.

late complications 1/stiffness 2/heterotopic ossification 3/unreduced dislocation 4/recurrent dislocation 5/osteoarthritis after sever fracture dislocation.

Pulled elbow- subluxation

of head of radius this conation occur in infancy and early childhood.

Mechanism of injury is a traction force applied to the elbow in pronatione leading to subluxation of the head which becomes impacted in the orbicular ligament .

this condition responds dramatically to quick movement of the forearm in to full supination .

Pulled elbow

Mechanism of pulled elbow

not the radial dislocation

Full supination for

mangmente of pulled elbow