Elbow Anatomy and biomechanic powerpoint .pptx

Elbow

1. FRACTURE AROUND THE ELBOW Capt. Myo Min Htet PG-1

2. Outline Elbow Anatomy Distal Humerus Fracture Fracture Of The Radial Head Coronoid Process Fracture Olecranon Fracture Capitellum Fracture

3. Elbow Anatomy Three distinct joints humeral(trochlea) – ulnar humeral(capitellar) – radial proximal radial-ulnar(PRUJ)

4. JTC 06 Factors Responsible for Elbow Stability: Bony Anatomy Normal muscle forces drive elbow posteriorly Brachialis: base coronoid Biceps: radial tuberosity Resist AP forces: Coronoid process Radial Head

5. Ligamentous Stability LCL MCL

6. DISTAL HUMERUS FRACTURE Epidemiology high-energy injuries but an increasing number of comminuted osteoporotic fractures are now seen. A ssociated with vascular or nerve damage Elbow dislocation Terrible triad injury Volkmann contracture

7. Mechanism of Injury The fracture is related to the position of elbow flexion when the load is applied

8. AO/OTA classification Type A – extra-articular supracondylar fracture Type B – intra-articular unicondylar fracture (one condyle sheared off) Type C – bicondylar fracture with varying degree of comminution

9. TYPE A – SUPRACONDYLAR FRACTURES R are in adults U sually displaced and unstable (There is no tough periosteum to tether the fragments )

10. Treatment of Type A Fracture ORIF is treatment of choice. The distal humerus is approached through a posterior exposure. sometimes possible to fix the fracture without recourse to an olecranon osteotomy using a triceps elevating approach. simple transverse or oblique fracture can usually be reduced and fixed with a medial and lateral contoured plate and screws.

11. TYPES B AND C – INTRA-ARTICULAR FRACTURES H igh-energy injuries with soft-tissue damage Swelling is considerable but, if the bony landmarks can be felt, the elbow is found to be distorted X-rays The fracture extends from the lower humerus into the elbow joint.

12. Treatment Undisplaced type B and C fractures P osterior slab with the elbow flexed almost 90 degrees M ovements are commenced after 2 weeks A lways obtain recheck X-rays a week after injury

13. Displaced type B and C fractures If the appropriate expertise and facilities are available, open reduction and internal fixation is the treatment of choice for displaced fractures in adult. The danger with conservative treatment is the strong tendency to stiffening of the elbow and persistent pain

14. In adults the use of plates and screws is preferred over lag screws or cannulated screws, even for unicondylar fractures Parallel or orthogonal plates are used depending on the fracture configuration of the lateral column Pre-contoured locking plates- help maintain position in osteoporotic bone Postoperatively the patient is provided with a sling for comfort but immediate active mobilization is initiated with the patient lying supine and the shoulder flexed to 90 degrees.

15. Orthogonal plates

16. Pre-contoured locking plates

17. Alternative Methods Of Treatment Elbow hemiarthroplasty r eplacement of the distal humerus alone role for the treatment of very comminuted fractures in elderly osteoporotic patients

18. Total elbow replacement unreconstructable distal humerus fracture

19. The ‘bag of bones technique ’ Indication Patient with risks of surgery Elbow can be placed in a cast at 90 degrees of flexion or collar and cuff if tolerated for 2–3 weeks to allow initial healing and for the pain to settle.

20. Treatment algorithm distal humerus fracture

21. FRACTURE OF THE RADIAL HEAD Epidemiology most common fracture of the elbow in adults Can be combined with high energy injuries Elbow dislocation Coronoid fracture Collateral ligament injuries

22. Mechanism of injury Fall on the elbow or fall on an outstretched hand with elbow extended. Clinical presentation pain and tenderness along lateral aspect of elbow limited elbow or forearm motion, particularly supination/pronation

23. Mason Classification Type 1 - Non displaced fracture Type 2 - Minimal displacement with angulation or impression (>2 mm) Type 3 - Comminuted fracture Type 4 - Radial head fracture with associated elbow dislocation

24. Imaging Plain X-ray AP and lateral elbow check for fat pad sign indicating occult minimally displaced fracture CT or MRI Identify associated injuries in complex fracture dislocations Ligamentous injury skeletally immature patient

25. Treatment Non-operative Short Period of Immobilization Followed By Early ROM Indications isolated minimally displaced fractures with no mechanical blocks (Mason Type I)

26. Operative ORIF Indications  Mason Type II with mechanical block  Mason Type III where ORIF feasible  presence of other complex ipsilateral elbow injuries

27. Fragment Excision (Partial Excision) Indications fragments less than 25% of the surface area of the radial head or 25%- 33% of capitellar

28. Radial head arthroplasty Indications Comminuted fractures (mason type III) with 3 or more fragments where ORIF not feasible and involves greater than 25% of the radial head

29. Radial head resection Indications  low demand, sedentary patients  in a delayed setting for continued pain of an isolated radial head fracture

30. Treatment algorithm of radial head fracture

31. Complications Displacement of fracture Posterior interosseous nerve injury (with operative management) Loss of fixation Infection Heterotopic ossification Stiffness Elbow and/or forearm instability

32. JTC 06 CORONOID PROCESS FRACTURE Isolated fracture is UNCOMMON Usually occurs in association with other elbow injuries dislocation olecranon fracture

33. Mechanism of injury axial load with elbow in slight flexion Clinical presentation Symptoms of elbow deformity & swelling Elbow pain Forearm or wrist pain may be a sign of associated injuries

34. Imaging Radiographs recommended views : AP and lateral elbow views findings : interpretation may be difficult due to overlapping structures CT scan useful for high grade injuries and comminuted fractures

35. Regan & Morrey classification Type I coronoid process tip fracture Type II fracture of 50% or less of height Type III fracture of more than 50% of height

36. Treatment Nonoperative Indications Type I, II, and III that are minimally displaced with stable elbow

37. Operative ORIF with medial approach Indications  type I, II, and III with persistent elbow instability  posteromedial rotatory instability

38. ORIF with posterior approach Indications  Olecranon fracture dislocation  Terrible triad of elbow

39. Hinged external fixation Indications  large fragments  poor bone quality  Difficult revision cases to help maintain stability

40. Complications  Recurrent elbow instability : especially medial-sided  Elbow stiffness  Posttraumatic arthritis  Heterotopic ossification  Early failure : associated with failure to recognize and repair underlying elbow instability

41. Terrible Triad Injuries A traumatic injury pattern characterized by Elbow dislocation Radial head fracture Coronoid fracture

42. OLECRANON FRACTURES Mechanism of injury Comminuted # due to direct blow or fall on the elbow Transverse # due to traction when the patient falls onto the hand while the triceps muscle is contracted In severe injury, associated with subluxation or dislocation of elbow joint ( ulno -humeral joint)

43. Fracture line always enters into the joint and may damage to articular cartilage. Clinical features  Bruises over elbow suggests comminuted # if tricep is intact and elbow can extend  In transverse # , gap is palpable

44. Imaging X-ray  AP view  Lateral view is essential  Check position of radial head for dislocation

45. JTC 06 AP View Lateral View Oblique View (sometimes helpful)

46. Classification Mayo Classification Based on comminution, displacement, fracture dislocation Type I : undisplaced fractures Type II displaced stable fractures Type III fractures with unstable ulnohumeral joint Each type subdivivded according comminution

47. JTC 06 Treatment Objectives Restoration of the articular surface Restoration and preservation of the elbow extensor mechanism Restoration of elbow motion and prevention of stiffness Goal is to begin early ROM Prevention of complications

48. Comminuted # with triceps intact  Should be treated severe bruises  Rest the arm in a sling for a week, further X-ray should be taken and if there is no displacement, encourage movement. Undisplaced transverse  Treat with close immobilization with 60’ elbow flexion with POP cast for 2-3 weeks and exercise

49. Displaced transverse #  ORIF with tension band wiring

50. Displaced comminuted #  ORIF with plate and bone graft

51. Treatment algorithm of olecranon fracture

52. Complications  Stiffness  Non-union  Ulnar nerve injury  OA

53. CAPITELLUM FRACTURES Epidemiology rare articular fracture that is usually more extensive than it initially appears involvement of the trochlea and posterior humerus common Mechanism of injury fall on outstretched hand

54. Clinical features Elbow is typically held at around 70 degrees of flexion Lateral side of the elbow is tender Bruising on the lateral side of the elbow Imaging X-ray AP and lateral of the elbow Best demonstrated on lateral radiograph CT scans Can be helpful in clarifying the diagnosis and extent of the injury

55. Classification

56. Treatment Nonoperative Posterior splint immobilization for < 3 weeks Indications nondisplaced type I and type II fractures (<2mm displacement)

57. Operative Open reduction and internal fixation Indications  displaced type I fractures (>2mm)

58. Fragment excision Indications  displaced (>2mm) type II fractures  Displaced (>2mm) type III fractures Complications Stiffness Non-union Instability Ulnar nerve injury

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