radial head fracture_and OLECRANONfracture.pptx

radial head fracture_and OLECRANON

1. Radial head Fracture, Proximal ulna Fracture Dr. Bijay Kumar Shrestha 1 st Year Resident Department Of Orthopedics Surgery KMCTH

2. Road map Introduction Anatomy Pathophysiology and Pathoanatomy Clinical Evaluation Classification Treatment

3. Radial head Fracture

4. Introduction Most common fractures of elbow Isolated or as part of more complex elbow injury Common in ages group 20 - 60 years Most fractures are treated conservatively Nonunion and fracture displacement are rare

5. Applied Anatomy Hinged joint supported by strong collateral ligaments Radial head articulates with Capitulum Medial ulna articulates with trochlea Neurovascular structures running down arm pass anterior and posterior to joint

6. Bony anatomy Radius Head Neck Coronoid process Radial notch of ulna Ulna Ulna Olecranon Capitellum Olecranon fossa Groove for ulnar nerve Trochlea In extension: anterior view In extension: posterior view

7. Ligaments around elbow joint

8. Muscles anatomy Radial nerve Deep branch Superficial branch Radial artery Brachioradialis muscle Brachialis muscle Radial recurrent artery Supinator muscle Median nerve Ulnar nerve Brachial artery Pronator teres Ulnar artery ulnar recurrent artery Flexor group muscles origin

9. Biceps Brachialis Ulnar nerve Median nerve Brachial artery Radial nerve Joint capsule of elbow Brachioradialis Arcade of Frohse Deep branch of radial nerve Superficial branch of radial nerve Radial artery Biceps tendon Ulnar artery Median nerve Anterior interosseous nerve Musculocutaneous nerve

10. PATHOANATOMY Concave dish of radial head articulates with capitellum Flattened articular margin articulates with sigmoid (radial) notch of ulna

11. PATHOANATOMY Nonarticular margin(1/3 rd ) - more rounded and often devoid of cartilage “safe zone” for placement of a plate on the nonarticular margin Vascular supply of the radial head is supplied by branches of the radial recurrent artery

12. Mechanisms of Injury for Radial Head Fractures Low energy mechanisms fall from standing height Higher-energy fractures like Sports, motor vehicle collisions Valgus load Impaction of radial head into the capitellum Fracture of radial head Associated with Rupture of the MCL

13. ….. contd 2. Trauma Postero -lateral rotatory subluxation of radial head Redial head impaction over capitellum Fracture of anterior portion of radial head , Associated with rupture of LCL .

14. ….. contd High velocity Trauma An axial forearm load Radial head impaction with capitellum Radial head fracture May be associate With fracture of coronoid or rupture of the interosseous membrane and distal radioulnar joint ligaments

15. Associated Injuries with Radial Head Fractures Tears of LCLs and/or MCLs Dislocations of elbow Fractures of the coronoid, capitellum , olecranon Rupture of the interosseous membrane

16. Signs and Symptoms Pain Swelling Stiffness of elbow Ecchymosis Tenderness over lateral epicondyle or medial epicondyle

17. Signs and Symptoms Loss of terminal extension Shoulder and wrist joint examined for associated injuries May associate with Distal radio-ulnar joint tenderness and instability

18. X-ray imaging

19. Greenspan view

20. CT Image

21. CT Image

22. MRI While magnetic resonance imaging may be useful to define the presence of associated collateral ligament injuries

23. Classification Mason Type I : fracture as a fissure or marginal sector fracture without displacement; Type II : as a marginal sector fracture with displacement Type III : as a comminuted fracture involving the whole head Type IV : injury was subsequently described which includes any radial head fracture associated with an elbow dislocation

24. Management

25. Management Non operative treatment Operative treatment

26. Non operative treatment Most radial head fractures are treated conservatively (Mason types I and II) Nonunion and fracture displacement are rare Undisplaced or minimally displaced radial head fractures Radial head fractures without motion impairment

27. ….. contd Immobilized for 2 or 3 days for comfort Active motion is encouraged Aspiration of hemarthrosis Careful radiographic and clinical follow-up

28. … contd Relative Contraindications- Block to forearm rotation Incarcerated intra-articular fragment With retained intra-articular loose bodies

29. Operative treatment Younger patients with three or fewer fragments Displaced fracture > 2 mm Fracture involving >30 % of the articular surface Mason types II and III fractures Radial head fractures with motion impairment

30. TREATMENT OF MASON TYPE II FRACTURES Mini-fragment screws, with or without buttress plate placed If remaining articular surface is small, resection with radial head replacement is necessary If the elbow is stable, resection without replacement has shown good results

31. TREATMENT OF MASON TYPE III FRACTURES High velocity injury May occur with elbow dislocation Less frequently appropriate for ORIF Radial head resection may be a good option Prosthetic replacement with metallic implants

32. …. contd Unreconstructable comminuted - Radial head arthroplasty Contraindication Radial head arthroplasty Gross wound contamination Radial neck cannot be reconstructed Capitellum is deficient or missing

33. Approaches of operative management Kocher approach Kaplan approach

34. LATERAL APPROACH TO THE ELBOW Excellent approach Incision Avoid radial nerve Separate origin of extensor muscles

35. Expose radiohumeral joint. Elevate brachioradialis and extensor carpi radialis longus muscles Incise capsule to expose lateral aspect of the elbow joint .

36. LATERAL J-SHAPED APPROACH TO THE ELBOW (KOCHER ) Incision Separate ecu from anconeus Divide distal fibers anconeus Reflect common origin of extensor muscles Incise the joint capsule longitudinally

37. Postoperative Care: Arm placed in molded above elbow back slab at 90º At 3 to 7 days, splint removed and arm supported sling Active and active assisted exercise are begun Discontinue sling at 3 weeks Strengthening performed after fracture healing is secure Indomethacin for a 3-week period in order to prevent heterotopic ossification.

38. FRACTURES OF THE OLECRANON

39. Introduction Accounts for 8% to 10% of all elbow fractures younger individuals - high-energy trauma older individuals - simple fall May associate with transolecranon fracture dislocations

40. PATHOANATOMY AND APPLIED ANATOMY Contributes to two articulations Ulnohumeral joint Proximal radioulnar joint Triceps tendon insertion onto at tip of olecranon

41. Mechanisms of Injury for Posterior Ulna Fractures Result from either direct or indirect elbow trauma Direct trauma - falling on the tip of the elbow Indirect trauma - falling on partially flexed elbow with indirect forces generated by triceps muscle avulsing olecranon Higher energy trauma motor vehicle collisions

42. Associated Injuries Given the subcutaneous location of the olecranon, open fractures are not uncommon and have a reported rate of 2% to 30% of fractures . Transolecranon fracture-dislocations may be associated with injuries to the coronoid process or segmental fractures of the ulna

43. Signs and Symptoms Pain Swelling and deformity Look for associated injuries shoulder, forearm, wrist, or hand injuries vascular status forearm compartments

44. Imaging Studies

45. Classification of Olecranon Fractures Mayo classification Type I ( undisplaced ) Type II(displaced but stable) Type III (unstable ) Each group subdivided into Comminuted (A ) fractures Non-comminuted (B ) fractures

46. Classification of Olecranon Fractures Classified by Schatzker Based on fracture pattern

47. Management Nonoperative Treatment Operative Treatment

48. Nonoperative Treatment Nondisplaced fracture or minimally displaced fracture Significant medical comorbidities Techniques Immobilised for 2 to 3 weeks Gentle active-assisted flexion is started avoiding active extension At 6 weeks , active motion against gravity Resistive exercises started at 3 months

49. Operative Treatment Majority of olecranon fractures are treated surgically Most fractures are displaced Comminuted fractures are associated with elbow instability

50. Simple olecranon fractures without comminution Tension-band wiring, Plating

51. Tension Band W iring Technique Create compression at articular end at fracture site Simple transverse olecranon fractures Contraindication Oblique fracture Comminuted fracture Fracture distal to the sigmoid notch Poorer outcomes elbow instability fractures of the coronoid and radial head

52. Olecranon plating Advantage comminute fractures distal olecranon fractures Complex fracture-dislocations . Allows lag screw fixation of the olecranon Provides good stability needed to obtain union Initiate an early range of motion

53. Newer precontoured plates provide more screw locking screw bend to match olecranon anatomy

54. Approach Tension Band Wiring Position Posterior midline incision Fasciocutaneous flaps are raised Ulnar nerve protected Plane between ECU and FCU developed Subcutaneous border of the ulna is exposed Fracture reduced extending elbow

55. Approach Plate Fixation