HUMERUS AND ELBOWHUMERUS AND ELBOW

By: Fatma Al-GhaithiBy: Fatma Al-Ghaithi mentor: Dr. Asma Al-Balushimentor: Dr. Asma Al-Balushi

HUMERUS AND ELBOWHUMERUS AND ELBOW AnatomyFractures: -shaft of humerus -distal humerus -radial head -ulnerManagementDislocations and sublaxationSoft tissue disorders

Anatomy of the humerusAnatomy of the humerus

All of the following are true except:

A-the wrist flexors originate from the medial epicondyle.

B-the only 2 structures contained in the posterior compartment are the triceps muscle and the ulner nerve.

C-median nerve symptoms may develop if supracondylar process fractured, which is a variant in some people.

D-the most vulnerable structure for injury in midshaft humeral fracture is the radial nerve.

All of the following are true except:

A-the wrist flexors originate from the medial epicondyle.

B-the only 2 structures contained in the posterior compartment are the triceps muscle and the ulner nerve. (radial n)

C-median nerve symptoms may develop if supracondylar process fractured, which is a variant in some people.

D-the most vulnerable structure for injury in midshaft humeral fracture is the radial nerve.

Compartments of the armCompartments of the arm

1) The anterior compartment contains three muscles:

-the biceps, the brachialis, and the coracobrachialis.

-the brachial artery. -median nerve, musculocutaneous nerve, and

ulnar nerve. 2) the posterior compartment contains: -the triceps

- radial nerve.

Clinical featuresClinical featureshistoryhistory

• pain

• Past medical history

• occupational factors

• mechanism of injury

• numbness or weakness

Humeral shaftHumeral shaft# #

• The most common site is the middle one 3ed.

• The most common associated injury is the radial n. (often is neuropraxia, resolves spontaneously).

Humeral Shaft FracturesHumeral Shaft Fractures

Management of humeral shaftManagement of humeral shaft# #

• Nonoperative.1)Coaptation (sugar tong) splint + sling for nondisplaced.(for 10-14

days)2)Hanging cast: displaced or comminuted #.Operative for:-open #- Multiple injuries that preclude mobalization.- b/l fracture - Poor reduction- Poor pt. compliance.- Failure of closed treatment.- Pathological #.*** isolatead radial n. injury is not an indication of operation.

Supracondylar fracturesSupracondylar fractures

• Two types:

1)supracondylar extension #.

2)supracondylar flexion #.

• All of the following statements regarding supracondylar extension fractures are true except:

a) They generally result from a fall on the outstretched arm.

b) They are more common in adults than in children.

c) They are associated with the development of Volkmann’s ischemic contracture.

d) Associated median nerve injury may occur with this injury.

• All of the following statements regarding supracondylar extension fractures are true except:

a)They generally result from a fall on the outstretched arm.

b)They are more common in adults than in children.

c)They are associated with the development of Volkmann’s ischemic contracture.

d)Associated median nerve injury may occur with this injury.

What is the peak age incidence for this type of fracture?

• The peak incidence of supracondylar fracture is in children 5 to 10 yrs.

Radiological findingsRadiological findings

1. Anterior fat pad.2. Posterior fat pad.3. Anterior humeral line. 4. Radial head contour. 5. Ossification centers. CRITOE 6. Hourglass sign. 7. Distal humerus. 8. Ulna/Olecranon.9. Clinical correlation.

symmetric figure of eight/hourglass sign at the distal humerus; also notice the posterior fat pad?

• Anterior and posterior fat pad signs

.

• This radiograph demonstrates abnormal alignment of the anterior humeral line strongly suspicious for fracture. (The anterior humeral line of a toddler/child must also intersect the

middle third of an ossified capitellum; also note the posterior fat pad and sail sign.)

This radiograph depicts a normal anterior humeral line

Here is a radiograph with both a sail and posterior fat pad sign . Posterior fat pad is never normal and always signifies fluid in the intraarticular space. in the setting of trauma, this

strongly implies fracture of an articular surface .

Gartland Classification for Extension-Type Supracondylar Fractures

Marx: Rosen's Emergency Medicine, 7th ed

Type 1Nondisplaced fracture

Type IIDisplaced fracture with intact posterior cortex

Type IIIDisplaced fracture with no cortical contact

A: Posteromedial rotation of the distal fragment

B: Posterolateral rotation of the distal fragment

supracondylar extension #.Supracondylar flexion #

Mechanism of injury

Fall on outstretched hand.Direct blow to the posterior aspect of flexed elbow.

presentationElbow extended, S-shaped configuration

Flexion

complicationsbrachial a. and median n. injuries, compartment syndrome (Volkmann’s ischemic contracture).

Cubitus varus deformity.

Ulner n. injury (the most common injury)

Stiffness of the joint.

Cubitus valgus.

X-ray findingsPosterior fat pad

Abnormal anterior humeral line

Increase angulation.

the anterior humeral line intersect the capitellum either normally or posteriorly.

managementNondisplaced: splint or cast flexed to 90.

Minimal Displaced: splint or cast, 110-120 flexion.

Total displacement: prompt reduction, followed by percutaneous pin fixation or internal fixation

Type II: manipulated into extension then immobilized by long arm cast or with percutaneous pins.

Type III: open reduction.

supracondylar extensionsupracondylar extension.# .#

Steps in reduction of a

displaced supracondylar

fracture

Tips for reduction and immobilizing distal humerus#

• With minimally displaced supracondylar #, the greater the flexion at elbow, the greater the chance of vascular impairment. so we flex it to 110-120.

• Medially displaced # are immobilized with forearm pronated, and laterally displaced # is immobilized in supination.

• What is shown in this x-ray:A) normal x-rayB) radial head sublaxationC) supracondylar fracture

• Supracondylar fracture. 1. Anterior fat pad, Posterior fat pad, 2. Anterior humeral line: Abnormal. 3. Radial head contour: Normal. 4. Distal humerus: Abnormal. The metaphysis of the distal

humerus on the AP view shows two irregularities. 5. Ulna/Olecranon: normal

??

Joint effusion. No visible fracture 1. Anterior fat pad2. Posterior fat pad3. Anterior humeral line:

Normal. 4. Radial head: Normal. 5. Ossification centers:

The capitellum and radial head centers are ossified.

6. Hourglass sign: Absent. This indicates that the lateral view is oblique.

7. Distal humerus: No irregularities seen.

8. Ulna/Olecranon: Normal.

Transcondylar and intercondylar

• Both more common in elderly.

• Neurovascular complications in intercondylar fractures are not common.

• Difficult to heal and treat:

-open reduction, internal fixation.

-early mobilization.

condylar # condylar # in childrenin children

• Lateral condyle are the 2ed most common # in children involving the elbow joint after extension supracondylar #.

• Medial condyle # are rare.• Management: -closed reduction/cast <2 ml

displacement.

-closed reduction/pin

fixation (3-4 weeks) >2 mm

Medial epicondyle epiphysis (arrow) trapped within the

elbow joint following avulsion

All of the following are true regarding olecranon # except”

a) Occur more common in children than adults.b) Displacement of > 2 cm is considered an

indication for surgery.c) The most vulnerable structure to injury is the

ulner n.d) The anatomic integrity of the olecranon is

essential for triceps strength and normal function of the elbow.

All of the following are true regarding olecranon # except”

a) Occur more common in children than adults.b) Displacement of > 2 cm is considered an

indication for surgery.c) The most vulnerable structure to injury is the

ulner n.d) The anatomic integrity of the olecranon is

essential for triceps strength and normal function of the elbow,

little Leaguer's elbowlittle Leaguer's elbow

• trauma to immature epiphyses by repetitive throwing.

• Avulsion of the medial epicondyle or compression fracture of the subchondral bone of the lateral condyle or radial head.

• This diagnosis should be sought in an athletic adolescent with medial epicondyle or radial head pain in the absence of acute injury by history.

• Adolescents with this condition should be forced to rest the elbow.

?

Impression: Joint effusion. Ulna fracture .

1. Anterior fat pad: Abnormal.

2. Posterior fat pad: Present,

3. Anterior humeral line: Normal.

4. Radial head: Normal. 5. Ossification centers: Only

the capitellum is ossified.6. Hourglass sign: Although

the lateral view appears to be somewhat oblique, an hourglass sign is present.

7. Distal humerus: No irregularities seen.

8. Ulna/Olecranon: Linear lucency down the center of the long axis of the ulna best seen on the AP view.

?

Radial head fractureRadial head fracture

Radial head fractureRadial head fracture

• Type I: undisplaced fractures

• Type II: marginal fractures (involving <30% of the articular surface) with displacement

• Type III: comminuted fractures. 

• Type IV: any of the above with elbow dislocation

Radial head fractureRadial head fracture

• Management:

Type I: sling, early mobilization (24-48 hrs), aspiration of hemarthrosis and injection of bupivacaine.

Type II: as above or: radial head excision

Type III: radial head excision

Type IV: treat dislocation and type of radial head in jury present accordingly.

Elbow dislocationElbow dislocation

• Is the 2ed most common large joint dislocating after the shoulder joint.

• most often dislocates posteriorly, although it may dislocate anteriorly, medially, or laterally.

Posterior dislocations are reduced with an assistant immobilizing the humerus and applying countertraction while traction is applied to the distal forearm. The ideal position is for the elbow to be flexed at 30 degrees with the forearm supinated while distal traction is applied .

Post reductionPost reduction managementmanagement

• immobilization in a sling and posterior splint.

• apply ice, elevate, gentle range-of-motion exercise in 3 to 5 days.

• The most serious complication of elbow dislocation is vascular compromise. Severe disruption results in injury to the brachial artery in 8% of cases.

Complete dislocation of the elbow.

Ulnar coronoid process fractures are often associated with this injury.

Subluxation of the Radial Head (Nursemaid’s Elbow)

-the radial head slips out from under the annular ligament.

-Generally caused by sudden traction of the forearm that extends and pronates the elbow (like the motion of pulling a child off the ground by his/her wrist).

-Most common in children aging 1 - 3years.girls > boys Recurrence : 20%.

iv. No associated swelling, ecchymosis, or neurovascular deficit.

Radiography - Normal findings.

Epicondylitis (Tennis Elbow)Epicondylitis (Tennis Elbow)

• an inflammatory process that involves the radiohumeral joint or lateral epicondyle of the humerus.

• It is a common exercise-related syndrome, is thought to be repetitive pronation and supination of the forearm.

• Clinical Features: - gradual onset. - dull pain over the lateral aspect of the elbow,

increased by grasping or twisting motions. - Tenderness over the lateral epicondyle. • To test for tennis elbow: the elbow is extended, the

forearm pronated, and the wrist fully dorsiflexed.• treatment: protection, (RICE), and medication.