elbow and forearm presentation - DR. KEYUR.pptx

Orthopaedic

1. Dr . Keyur Bhimani Resident Dept. Of Emergency Medicine Under guidance of Dr. Sarbari Swaika (Prof & HOD, Dept. Of Emergency Medicine) ELBOW AND FOREARM FRACTURE

2. The elbow is one of the more stable joints. Dislocations of the elbow rank third in large-joint dislocations. The mechanism of injury is usually a fall on an outstretched hand. Approximately 90% of all elbow dislocations are posterolateral .

3. The “terrible triad” injury consists of an elbow dislocation coupled with fractures of the radial head and coronoid . This injury creates an unstable joint and requires emergent orthopedic consultation.

4. The priority is to assess the neurovascular status of the brachial artery, ulnar nerve, and median nerve, as these structures may become entrapped. Perform neurovascular examination before and after manipulation. Neurologic complications most frequently involve the ulnar nerve and occur in up to 20% of elbow dislocations.

5. Brachial artery injuries are estimated to occur in 5% to 13% of elbow dislocations. Absence of a radial pulse before reduction, an open dislocation, and systemic injuries (such as those of the head, chest, and abdomen) are findings associated with arterial injury. If vascular injury is suspected, then angiography may be required to assess the extent of injury and need for repair.

6. Closed reduction can be accomplished by several methods. In the first; two-person reduction technique, position the forearm supine. While an assistant applies a stabilizing countertraction force on the upper arm, use one hand to apply a longitudinal traction on the wrist and forearm ( Figure ). With the other hand, manipulate the elbow to correct any medial or lateral displacement. Then apply slow and steady downward pressure to the proximal forearm with the other hand to help disengage the coronoid process from the olecranon fossa . Continue distal traction and flex the elbow.

7. In the second two-person technique, the patient is prone with the arm abducted and the elbow slightly flexed. The patient may also be supine with the arm adducted across the torso and the elbow slightly flexed (Figure ). Have an assistant apply longitudinal traction on the wrist and forearm. Then, grasp the elbow, positioning both thumbs on the olecranon , and apply firm pressure against the olecranon to push it up and over the trochlea and back into anatomic position. Apply countertraction with the fingers against the distal humerus .

8. A preliminary report described a single-person reduction technique with the patient in a seated position (Figure). Place an elbow in the patient’s antecubital fossa , then grasp the patient’s hand or wrist. Flex the patient’s forearm while leveraging a force into the antecubital fossa to bring the olecranon back into anatomic position. As this is a preliminary report of the technique, success and complication rates are not known with certainty.

9. The last technique is a modification of the Stimson hanging technique used in shoulder reductions (Figure). Place the patient prone with the elbow flexed over the edge of the stretcher. Support the humerus proximal to the elbow with a folded blanket or pillow. Suspend 5-lb weights from the wrist. The patient’s elbow should reduce over a period of several minutes. Gentle manipulation may be applied to the olecranon to aid reduction.

10. With reduction, a palpable “clunk” is felt as the olecranon is seated back in the trochlea . Move the elbow through its full range of motion to assess stability. Obtain postreduction films to determine reduction and identify fractures not previously identified. Inability to maintain reduction necessitates emergency orthopedic consultation.

11. If the joint is stable and good neurovascular status has been confirmed, splint with a long arm posterior splint with the forearm and wrist both in neutral position and the elbow at slightly less than 90 degrees of flexion. Arrange orthopedic follow-up in 1 to 2 days. Obtain emergency orthopedic consultation for irreducible dislocations, neurovascular compromise, postreduction instability, associated fractures, and open dislocations.

12. FRACTURES ABOUT THE ELBOW Elbow fractures can be divided into those of the distal humerus , proximal ulna, and proximal radius. The distal humerus includes the condylar structures and the articular surface ( trochlea and capitellum ). The proximal ulna includes the coronoid process and olecranon , and The proximal radius is essentially the radial head.

13. Radiographs of fractures about the elbow may reveal abnormal fat pads (Figure ). A traumatic hemarthrosis displaces fat from the olecranon fossa posteriorly (posterior fat pad), and the anterior fat pad may become prominent (“sail sign”). Treatment is initiated as though a fracture were identified with splint immobilization and orthopedic consultation.

14. DISTAL HUMERUS FRACTURES Routine ED care of nondisplaced distal humerus fractures with normal neurovascular function includes immobilization, ice, elevation, analgesics, and orthopedic referral. Displaced fractures or those with neurovascular compromise require immediate orthopedic consultation.

15. SUPRACONDYLAR FRACTURES Supracondylar fractures are the most common fracture about the elbow in children between 5 and 10 years of age, but can occur in adults, especially from high-velocity injuries. Two types: extension type (>95%), which are displaced posteriorly , flexion type (<5%), which are displaced anteriorly .

16. Treatment varies widely between nonoperative management to emergent surgical management. Treatment largely depends on the degree of displacement of the distal fragment and any concurrent neurovascular or soft tissue injury.

17. EXTENSION-TYPE SUPRACONDYLAR FRACTURES Injuries most often occur with a fall on an outstretched hand with the elbow in full extension. Examination reveals significant edema and tenderness at the elbow, a prominent olecranon , and a depression proximal to the elbow.

18. Nondisplaced fractures may be subtle and diagnosed only by the presence of a posterior fat pad, anterior “sail sign,” or disruption to the normal path of the anterior humeral line. Initially treat with immobilization using a long arm posterior splint, keeping the elbow at 90 degrees of flexion and the forearm in neutral rotation, followed by casting.

19. The presence of >20 degrees of angulation necessitates orthopedic consultation for reduction under anesthesia and possible pin fixation. In displaced fractures, the distal fragment will be displaced proximally and posteriorly . More severely displaced fractures may show medial or lateral displacement or rotation along the axis of the humerus (Figure 270-13).

20. Displaced fractures must be reduced and require orthopedic consultation. However, there is now a trend toward delayed reduction and fixation up to 24 hours after injury without evidence of complication, thus lessening the need for emergent orthopedic intervention. Indications for emergent consultation are vascular insufficiency or decreased perfusion, nerve injury, open fracture, or an irreducible fracture.

21. FLEXION-TYPE SUPRACONDYLAR FRACTURES Flexion-type fractures are rare. The mechanism of injury is a direct anterior force against a flexed elbow, resulting in anterior displacement of the distal fragment. Because the mechanism is direct force, these fractures are often open. Flexion-type injuries are more likely to require open reduction and pinning, particularly if an associated ulnar nerve injury is present.

22. COMPLICATIONS OF SUPRACONDYLAR FRACTURES Neurologic complications—resulting from traction, direct trauma, or nerve ischemia—have an incidence of 10% to 20%. Ulnar nerve injuries are uncommon, with the highest incidence reported iatrogenically from pin placement. Posteromedial displacement may involve the radial nerve, and posterolateral displacement can affect the median nerve.

23. There is a high incidence of anterior interosseous nerve injuries with supracondylar fractures. The mechanism of injury is usually traction or contusion. Because there is no sensory component to the anterior interosseous nerve, the injury can only be identified through motor testing by making the “OK” sign.

24. Absence of a radial pulse is an indicator of brachial artery injury, even if the hand appears warm, pink, and well perfused . Injury can be due to a partial or complete transection , an intimal tear and thrombosis, or entrapment within the fracture fragment of the brachial artery. Suspected or actual neurovascular injury requires emergency orthopedic consultation.

25. INTERCONDYLAR FRACTURES Intercondylar fractures, in which the condylar fragments are separated, are much more common in adults than in children. The mechanism of injury is a force directed against the posterior elbow.

26. Treatment is dependent on the amount of displacement of the fracture fragments. Nondisplaced intercondylar fractures are stable and can be treated initially with immobilization in a long arm posterior splint with the elbow flexed at 90 degrees and the forearm in neutral position. Obtain orthopedic consultation for treatment of displaced, rotated, or comminuted fractures or severe edema.

27. EPICONDYLE FRACTURES Lateral epicondyle fractures are uncommon, because the anatomic position of the condyle reduces its exposure to direct blows. When they do occur, lateral epicondyle fractures are usually avulsion fractures. These can be treated with immobilization in a long arm posterior splint, with the elbow flexed to 90 degrees and the forearm in supination , and orthopedic referral.

28. Patients present with pain over the medial elbow that is exacerbated by supination of the forearm and flexion of the forearm, wrist, and digits. Edema and tenderness are noted in the same area. Carefully test neurovascular function. Obtain standard radiographs with special attention to any intra- articular fragment. Comparison views of the unaffected contralateral elbow may be helpful for diagnosis.

29. Treat stable, nondisplaced or minimally displaced fractures from a low-energy mechanism nonoperatively , with early range of motion. ED treatment consists of long arm posterior splint immobilization, with the forearm in flexion and pronation , and orthopedic referral. High-energy injuries, open fractures, unstable joints, significant fragment displacement , an intra- articular fragment, and ulnar neuropathy are indications for emergency orthopedic consultation.

30. CONDYLE FRACTURES Lateral condyle fractures occur in children and are more common than their medial counterpart. They result from either a direct blow to the lateral elbow or from a fall on an outstretched hand. Patients complain of pain in the lateral elbow, and swelling is noted in the same area.

31. Medial condyle fractures are uncommon and are mostly limited to children. Mechanism of injury is from either a fall on an outstretched hand or excessive valgus stress. Medial pain and swelling are the prominent findings.

32. ED care of nondisplaced condyle fractures with normal neurovascular function includes long arm posterior splint immobilization, ice, elevation, analgesics, and orthopedic referral. Follow-up imaging every 2 weeks is recommended due to the risk of late displacement, which is treated with surgical fixation. Displaced fractures or those with neurovascular compromise require immediate orthopedic consultation.

33. ARTICULAR SURFACE FRACTURES TROCHLEA AND CAPITELLUM FRACTURES Isolated trochlea fractures are rare and are often associated with other elbow injuries, such as posterior elbow dislocations. Physical findings usually include swelling, tenderness, and limited movement of the elbow joint. Radiographic findings can be subtle, and CT or MRI may be required for diagnosis. Isolated capitellum fractures are also rare. They are usually associated with radial head fractures. Pain is present over the lateral elbow, and examination reveals lateral swelling, tenderness, and limitation of flexion and extension. Radiographic findings may be subtle and are best seen on a lateral view.

34. Can You See The Capitulum

35. CAPITELLUM FRACTURES ED treatment of articular surface fractures includes long arm posterior splint immobilization and orthopedic consultation. Complications are common and include limited flexion and extension, elbow joint instability, avascular necrosis, nonunion , and arthritis.

36. CORONOID FRACTURES Coronoid fractures are usually associated with posterior elbow dislocations as the trochlea impacts the coronoid . Rarely, a coronoid fracture can occur as an isolated injury secondary to elbow hyperextension. There is pain, swelling, and tenderness over the antecubital fossa . Radiographic visualization is best with lateral and oblique films. CT is often needed to make the diagnosis.

37. ED treatment should include long arm posterior splint immobilization with the elbow in flexion and the forearm in supination , ice, elevation, analgesics, and referral to an orthopedic surgeon within 24 hours. Due to the critical role the coronoid plays in elbow stability, early orthopedic referral is indicated even for isolated, nondisplaced fractures. Displaced fractures or those with joint instability require open reduction and internal fixation and frequently have poor outcomes.

38. OLECRANON FRACTURES Olecranon fractures represent up to 10% of upper extremity fractures. The mechanism is usually direct trauma or by a fall with forced hyperextension of the elbow. Associated injuries are common, including open fractures, dislocations, other fractures (especially of the radial head), and ulnar nerve injury.

39. Pain is present over the posterior elbow, and examination reveals swelling, tenderness, and occasionally crepitus . Ulnar nerve injury is common; therefore, a careful neurologic examination is required. Lateral radiographs offer the best view of the olecranon .

40. In adolescents, the epiphysis ossifies by 11 years of age and fuses by 16 years of age, so comparison films and the appearance of an abnormal fat pad can aid in the diagnosis. ED treatment includes long arm posterior splint immobilization with the elbow in flexion and forearm neutral, ice, elevation, analgesics, and referral to an orthopedic within 24 hours.

41. RADIAL HEAD FRACTURES Radial head fractures are the most common fractures of the elbow. They result from a fall on an outstretched hand, causing the radial head to drive into the capitellum . Associated injuries are common and may include capitellum , olecranon , and coronoid fractures, medial collateral ligament injury, medial epicondyle avulsion fracture, and elbow dislocation.

42. A specific associated injury, the Essex- Lopresti lesion, occurs when there is disruption of the triangular fibrocartilage complex of the wrist and the interosseous membrane between the radius and ulna, causing dissociation of the distal radioulnar joint. Do not miss this injury. Failure to recognize this injury can result in proximal migration of the radius, so obtain emergency orthopedic consultation

43. Radial head fractures

44. Radial head fractures cause pain in the lateral elbow, especially with pronation and supination of the forearm. On examination, there may be swelling laterally and tenderness with palpation of the radial head. Pronating and supinating the forearm with the elbow flexed allows the examiner to palpate the radial head. On standard elbow radiographs, radial head fractures may be subtle ( Figure ).

45. Radiographic clues include the presence of an abnormal fat pad or abnormal displacement of the radiocapitellar line away from the center of the capitellum (Figure ).

46. Nondisplaced fractures can be treated conservatively with immobilization and early range of motion exercises to avoid the development of a stiff joint. ED treatment consists of sling immobilization, ice, elevation, analgesics, and referral to an orthopedic surgeon or sports medicine specialist within 1 week. Consider aspiration of the joint hematoma in the ED to improve pain and facilitate early mobilization.

47. For displaced fractures or those with restricted range of motion, surgical repair is generally indicated, and orthopedic referral should be made within 24 hours. Complications of radial head fracture include chronic pain and restricted range of motion at the elbow.

48. FOREARM FRACTURES In adults, solitary fractures of the forearm are uncommon due to the close relationship of the radius and ulna. The fibrous interconnection between the radius and ulna transmits force above and below the injury. As a result, fractures usually occur at two or more sites or involve ligamentous injury or joint dislocation. Because distant structures are commonly injured, examine joints above and below the involved bones both clinically and radiologically .

49. Radius and Ulnar bones

50. FRACTURES OF BOTH RADIUS AND ULNA A large amount of force is necessary to fracture both the radius and the ulna. This occurs most often from vehicular trauma, falls from a height, or a direct blow. Force magnitude determines the injury type. Moderate forces produce transverse or mildly oblique fractures. High-impact forces produce comminuted and segmental fractures (often displaced).

51. Examination of the forearm reveals swelling, deformity, and tenderness. Carefully assess the neurovascular status. Nerve injuries can occur with severe open fractures, but are uncommon with closed injuries. Because of the excellent collateral circulation of the forearm, vascular compromise is generally not a major concern if either the radial or ulnar circulation is intact.

52. Treatment depends on the type of fracture. Torus or greenstick fractures with minimal angulation in children can be treated with immobilization in a long arm splint. Angulation >15 degrees warrants referral for closed reduction.

53. In younger children, treat displaced fractures with closed reduction and cast immobilization due to the continued remodeling that occurs after fracture healing. Perform closed reduction urgently in the ED to ensure appropriate alignment. Nondisplaced fractures in adults can be immobilized with a long arm splint and referred for urgent follow-up. All other fractures in adults require orthopedic consultation, ideally within 24 to 48 hours.

54. Complications include reduced ability to supinate and pronate , osteomyelitis , nonunion , malunion , neurovascular injury, and compartment syndrome (VIC). Emergent orthopedic consultation for fasciotomy is required.

55. I solated fractures o f the forearm

56. ULNA FRACTURES Isolated fractures of the ulna most often result from a direct blow to the forearm. A fracture resulting from the natural response to raise the forearm in defense of a strike is referred to as a nightstick fracture.  ISOLATED ULNA FRACTURE (NIGHTSTICK FRACTURE)

57. Nondisplaced fractures are immobilized in a sugar-tong splint and closely followed for subsequent displacement. Fractures with >50% displacement, with >10% angulation , or that involve the proximal third of the ulna are considered unstable. Obtain orthopedic consultation for unstable fractures.

58. MONTEGGIA’S FRACTURE-DISLOCATION Fracture of the proximal third of the ulna with a radial head dislocation is referred to as Monteggia’s fracture-dislocation ( Figure).

59. MONTEGGIA’S FRACTURE-DISLOCATION The associated radial head dislocation may be easily missed. Missing the radial head dislocation can lead to chronic pain, limited range of motion, and, possibly, radial head excision as treatment. Monteggia’s fracture-dislocations occur following a fall onto an outstretched hand or a direct blow.

60. Clinically, there is considerable pain and swelling at the elbow. The radial head may be palpable in an anterolateral or posterolateral location. The forearm may appear shortened and angulated.

61. An abnormal radiocapitellar line may aid in the diagnosis. Obtain consultation with an orthopedic surgeon. Monteggia’s fracture dislocations are generally treated with open reduction and internal fixation of the ulna fracture and closed reduction of the radial head dislocation. Complications include nonunion , recurrent dislocation, chronic pain, infection, and paralysis of the posterior interosseous nerve.

62. RADIUS FRACTURES FRACTURES OF THE PROXIMAL TWO THIRDS OF THE RADIUS Radius fractures can be divided into those in the proximal two thirds and those in the distal one third of the bone. Fractures of the proximal two thirds of the radius are often displaced by both the force of the injury and the action of the forearm supinators and pronators on the radius.

63. Typically, supination of the proximal segment and pronation of the distal segment are seen, although a fracture located beyond these muscle groups may have minimal deformity.

64. Displaced fractures require emergent orthopedic consultation. Nondisplaced fractures are treated with cast immobilization. Compartment syndrome is rare with these fractures. Most complications involve malunion or nonunion because of inadequate or lost reduction.

65. GALEAZZI’S FRACTURE-DISLOCATION Fracture of the distal third of the radial shaft accompanied by a dislocation of the distal radioulnar joint is known as Galeazzi’s fracture-dislocation (Figure ).

66. This injury results from falls on the outstretched hand in forced pronation or from a direct blow. Galeazzi’s fracture-dislocation is also referred to as Piedmont fracture, reverse Monteggia’s fracture, or fracture of necessity, reflecting the need for surgical intervention. There is localized tenderness and swelling over the distal radius and wrist. The radius fracture usually results in dorsal lateral angulation .

67. Obtain immediate orthopedic consultation in the ED. Complications include infection, nonunion , and malunion . If the radius heals with a rotational deformity, there may be pain at the distal radioulnar joint with extreme pronation and supination .