Injuries Around The Elbow

INJURIES AROUND THE ELBOW

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1- SUPRACONDYLAR FRACTURE 2- DISLOCATION ELBOW 3- FRACTURE OLECRANON 4- FRACTURE HEAD RADIUS 5- FRACTURES OF HUMERAL CONDYLES 6- EPICONDYLE FRACTURE 7- PULLED ELBOW

 SUPRACONDYLAR FRACTURE OF THE HUMERUS

MECHANISM OF INJURY AND TYPES OF SUPRACONDYLAR FRACTURES supracondylar

intercondylar

Extension type Extension type 

 Flexion type

 The trauma is usually due to a fall on the outstretched hand, the distal fragment is usually pushed backwards and displaced posteriorly and tilted backwards; this is the most common type of injury ( the extension type of S.C.Fr.) and accounts for 85% of cases  A much rarer type of injury is due to a direct trauma to the elbow or a fall on the flexed elbow, where the distal fragment is displaced anteriorly ( the flexion type of S.C.Fr.) and accounts for 5 % of cases  Another rare type is the intercondylar T- or Y- type fracture which occurs mainly in adults and accounts for 10 % of cases

Diagnosis A. Clinical picture

HISTORY  History of trauma; a fall on the outstreched hand or direct trauma to the flexed elbow  Severe elbow pain  Limited joint movements  Elbow swelling  May be symptoms of neuro-vascular injury (hand pain, paraesthesia, or loss of movements).

O/E INSPECTION: . Elbow swelling with obliteration of the fossae on the sides of the olecranon . S-shaped deformity when looking to the elbow from the sides . there may be forearm and hand swelling especially if presenting late, if the fracture was manipulated by somebody, or if it is associated with vascular injury.

PALPATION: . local tenderness around the elbow maximally over the distal end of the humerus.

. A step may be palpable between the proximal and distal fragments. . Crepitus may be palpated with movements.

The anatomical relation between bony landmarks (the medial and lateral humeral epicondyles and the tip of olecranon) is not disturbed ; i.e, they fall on a straight line when the elbow is extended and form a triangle in the flexed elbow.

MOVEMENTS:

. both active and passive elbow movements are limited by severe pain and may be associated with crepitus.

SPECIAL SIGNS:

. examine the forearm, wrist, and hand for evidence of associated vascular or nerve injury (pallor, weak or absent radial pulse, paraesthesia, pain with stretching the fingers, paralysis of hand intrensic muscles or long finger flexors).

B. X- Rays:

 EXT

FLEX

Plain X-ray of the elbow (AP and Lateral views) may show . In AP view the distal fragment is shifted or tilted sideways and rotated . In lateral view the fracture is seen most clearly; in the extension type the distal fragment is displaced posteriorly and tilted backwards. in the flexion type the distal fragment is displaced and tilted anteriorly

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FLEX

 EXT

TREATMENT A- REDUCTION: 

Undisplaced or minimally displaced fractures: No need for reduction. Displaced fractures: Must be reduced as soon as possible Closed Reduction is done under general anaesthesia (G.A) by traction and manipulation to correct sideways and front to back displacement, tilt, and rotation.Reduction is performed under x-ray control.

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Radial pulse must be palpated after reduction; if absent the elbow is gradually extended till the pulse returns

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X-Rays are taken to confirm reduction

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Indications for open reduction include: Open fractures Fractures which cannot be reduced by closed manipulation Vascular injury not improving by manipulation Vascular injury occurring after closed reduction Intercondylar fractures

B- MAINTAINING REDUCTION (FIXATION) : CAN BE DONE BY: • above elbow back slab in the reduced position, with collar en cuff sling for three weeks. • percutaneous wires passed through the humeral epicondyles fixing the distal fragment to the proximal fragment, then applying a collar en cuff sling for three weeks. Indications for percutaneous wire fixation (percutaneous pinning) include: * unstable fractures which displace after closed reduction * fractures associated with vascular injuries which improve after closed reduction to avoid redisplacement and vascular compression * after open reduction for one of the previously mentioned indications

C- CARE AFTER REDUCTION AND FIXATION: * collar en cuff sling and back slab are kept for 3 weeks, where they are removed to allow active movements of the elbow joint. * If percutaneous wires were applied, they are pulled out after three weeks.

COMPLICATIONS A- Early complications: 1. Vascular injury (injury of the brachial artery): - gangrene of the digits - Volkmann’s ischaemic contracture - ischaemic neurologic damage 2. Nerve injury: *The median nerve * The radial and ulnar

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B. Late complications:  Deformity from malunion  cubitus varus  Volkmann’s ischaemic contracture 

Myositis ossificans (Post-traumatic ossification)

4. Elbow stiffness 5. Nonunion: is very rare to occur in S.C.Fr

 CUBITUS VARUS

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DISLOCATION OF THE ELBOW JOINT

CAUSATIVE TRAUMA  Usually caused by a fall on the POSTERIOR  outstretched hand with the elbow in mild flexion Anterior  The radio-ulnar complex is usually  displaced posteriorly or postero-laterally (POSTERIOR DISLOCATION)  Rarely caused by fall on the back of the elbow with the radio-ulnar complex displaced anteriorly and olecranon broken (Anterior dislocation) MORE COMMON IN ADULTS THAN IN CHILDREN POSTERIOR DISLOCATION

Clinical picture:  - prominent tip of the olecranon on the posterior aspect of the elbow - the anatomical relation between bony landmarks (the medial and lateral humeral epicondyles and the tip of olecranon) is disturbed ; i.e, they do not fall on a straight line when the elbow is extended with the olecranon pointing far posteriorly

 Complete loss of passive and active movements of the elbow  Examination should include forearm and hand examination for associated vascular or nerve injury

Clinical picture:  - prominent tip of the olecranon on the posterior aspect of the elbow - the anatomical relation between bony landmarks (the medial and lateral humeral epicondyles and the tip of olecranon) is disturbed ; i.e, they do not fall on a straight line when the elbow is extended with the olecranon pointing far posteriorly

 Complete loss of passive and active movements of the elbow  Examination should include forearm and hand examination for associated vascular or nerve injury

Clinical picture:  The patient supports the forearm with the elbow in slight flexion  Local swelling may be severe with local bruises  Severe local tenderness maximally around the joint  Deformity: - prominent tip of the olecranon on the posterior aspect of the elbow - the anatomical relation between bony landmarks (the medial and lateral humeral epicondyles and the tip of olecranon) is disturbed ; i.e, they do not fall on a straight line when the elbow is extended with the olecranon pointing far posteriorly

 Complete loss of passive and active movements of the elbow  Examination should include forearm and hand examination for associated vascular or nerve injury

X- Rays:  Radiographs of the elbow joint in AP and Lateral views will show the type of displacement and excludes associated fractures

Treatment:  The dislocation should be reduced as soon as possible  Reduction is done under GA and muscle relaxant  Check movements after reduction and assess the joint stability  X- ray must be taken to confirm reduction and disclose associated fractures  Above elbow cast is applied for 3 weeks followed by active exercises with collar en cuff sling in between for another 3 weeks  Anterior dislocation needs open reduction and internal fixation of olecranon fracture

COMPLICATIONS A- Early complications: 1. Vascular injury (injury of the brachial artery): - gangrene of the digits - Volkmann’s ischaemic contracture - ischaemic neurologic damage 2. Nerve injury: *The median nerve * The ulnar and radial B. Late complications: 2. Volkmann’s ischaemic contracture 3. Myositis ossificans (Post-traumatic ossification) 4. Elbow stiffness

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FRACTURE OLECRANON It can be caused by :  - A fall on the elbow or by a direct trauma ; usually  comminuted fracture  - By a fall on the hand with sudden powerful contraction of triceps muscle usually  avulsion of the olecranon as a large single fragment  - Sometimes associated with dislocation elbow especially the anterior type

Clinically: - local pain, bruises, and tenderness - a gap may be palpable at the fracture site due to separation of the fracture fragments by triceps pull - inability to extend the elbow against resistance

FRACTURE OLECRANON Treatment: usually surgical and aims at: - restoring extensor mechanism if interrupted - restoring the articular surface of the olecranon - start early active movements Complications:  stiffness due to long immobilization  non-union due to inadequate reduction and fixation  osteoarthritis due to improper reduction of the articular surface

FRACTURE HEAD RADIUS It is common in adults ,rare in children It is caused by a fall on the outstretched hand •It causes local pain and tenderness on the lateral side of the elbow maximal over the dimple overlying the radial head. •There is limitation of rotation of the forearm and elbow extension •X-Rays show the fracture which may be a split fracture, a single sector fracture, or a comminuted fracture

FRACTURE HEAD RADIUS Treatment depends on the type of fracture: - undisplaced fracture is treated in collar en cuff sling and encouraging gradual active movements - a single large fragment can be openly reduced and fixed with a screw - a comminuted fracture is treated by excision of the radial head Complications : - Joint stiffness - Myositis ossificans - Degenerative arthrosis of the radio-humeral joint

FRACTURES OF THE HUMERAL CONDYLES  Condylar fractures are relatively uncommon, they occur mainly in children  The lateral condyle is fractured much more common than the medial condyle  The usual cause is a fall, muscle pull is involved in the mechanism of injury; - common extensor origin avulsion  lateral condyle fracture - common flexor origin avulsion  medial condyle fracture  In children the greater part of the detached fragment is cartilagenous, so the fragment appears much smaller on X-ray than it is in fact  It is essential to reduce the displacement because the fracture involves the joint surface as well as the growth plate in most cases

lateral

medial

Treatment :

- a simple crack without displacement is treated in above elbow splint or cast for 3 weeks followed by a course of mobilizing exercises for the elbow - displaced fractures should be well reduced to avoid permanent disability; . an attempt to reduce the fragment by closed manipulation under G.A and x-ray control, if successful a plaster is applied and kept till healing of the fracture followed by physiotherapy . open reduction is indicated if closed reduction fails to give perfect reduction or if the fracture redisplaces after reduction. The fracture is then fixed in position by wire pins (K-wires)

Complications: 1. Non-union:  cubitus valgus 2. deformity 3. delayed ulnar nerve palsy 4. Osteoarthritis

FRACTURES OF THE HUMERAL EPICONDYLES a.  

It occurs more often in children than in adults the fracture usually affects the medial epicondyle it is usually caused by avulsion injury, the epicondyle being pulled off by the attached common flexor origin during a fall TREATMENT - undisplaced cases; symptomatic treatment - severe displacement requires open reduction and K-wire fixation followed by physiotherapy COMPLICATIONS  1. Injury to the ulnar nerve  2. inclusion of the medial epicondyle fragment in the joint  3. non-union due to muscle pull on the fragment

medial

lateral

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PULLED ELBOW (SUBLUXATION OF THE HEAD OF THE RADIUS )  The radial head is pulled partly out of the annular ligament  It is caused by sudden lifting of a child by the wrist  There is local pain and the elbow is held in pronation with restricted extension and supination  Treatment by closed reduction by pushing the forearm upwards and rotating it alternatively into supination and pronation

The Wrist and Hand

Articulations The wrist comprises three movable joints: • Distal radio-ulnar joint. • Radio-carpal joint (between the radius and the proximal row of carpal bones). • Mid-carpal joint (between the proximal and distal rows of carpal bones).

Movement

Extension (dorsiflexion), Flexion (palmarflexion), Ulnar deviation, radial deviation, also pronation and supination (an arc of motion about 120 at radioulnar joint .

Deformities Congenital: • Carpal fusions: Coalition of two or more carpal bones. • Transverse absence: Failure of formation most common. at the junction o the middle and upper third of the forearm. • Longitudinal deficiencies: •Radial deficiency or radial club hand: The wrist is in marked radial deviation. There is absence of the whole or part of the radius, also often the thumb, scaphoid and trapezium fail to develop normally.

•Treatment consist of manipulation and splintage. Surgical treatment is intended to improve appearance and function. Treatment aims at centralization of the carpus on the ulna. In bilateral cases, elbow stiffness is a contraindication to corrective surgery because radial deviation of the wrist is the only position in which the hand can reach the mouth or perineum.

•Ulnar deficiency: The wrist is in ulnar deviation due to partial or complete absence of the ulna. Treatment consist of stretching and splintage soon after birth. Surgical correction is reserved for marked deformity. • Madelung’s deformity: (congenital or acquired)Deformed distal radius with volar (anterior) and radial (lateral) displacement of the carpus with the distal ulna being prominent as a hump on the back of the wrist. Surgical treatment is needed if there is severe deformity or wrist pain.

Arthrogryposis multiplex congenita: Multiple, non progressive joint contractures are noted at birth. The limbs appears atrophic with waxy skin lacking normal joint creases. Treatment is in the form of serial manipulation and casting. Surgical correction in severe, resistant or reccurent cases.

Acquired deformities: • Physeal injuries: Fracture separation of the distal radial epiphysis may result in partial fusion of the physis (bony bar is formed between the metaphysis and epiphysis) with asymmetrical growth deformity of the wrist. Treatment is by excision of the formed bony bar if it is small. Correction of the deformity by suitable osteotmy is also done.

• Forearm fractures: Malunion of distal radial fractures results in Madelung’s deformity. • Rheumatoid Deformities: This is commonly in the form of radial deviation at the wrist and ulnar deviation of the fingers also forward subluxation of the carpus and radio ulnar subluxation may occur. • Drop wrist: result from radial nerve injury with inability to extend the wrist which drop into flexion.

Acquired Finger deformities: • Skin contracture: Cuts and burns of the palmar skin are liable to heal with contracture. • Dupuytren’s contracture: The superficial palmar fascia (palmar aponeurosis) fans out from the wrist towards the fingers, sending extensions across the metacarpophalangeal joints to the fingers. Hypertrophy and contracture of the palmar fascia lead to puckering of the palmar skin and fixed flexion of the fingers.

Muscle contracture Volkmann’s ischemic contracture: Contracture of the forearm muscles that may follow circulation insufficiency due to injuries at or below elbow Shortening of the long flexors cause fingers to be held in flexion deformity. They can only be extended when flexing the wrist to relax the long flexors. Shortening of the intrinsic muscles: This lead to a characteristic deformity with flexion at the metacarpophalangeal joints with extension o the interphalangeal joints and thumb adduction. This is the intrinsic plus hand.

•Tendon lesions: Mallet finger: The distal interphalangeal joint is held in flexion due to injury of the extensor tendon of the terminal phalanx. Passive extension is normal. It may be associated with a small bony fragment from the tendon insertion into the distal phalanx. Treatment is by splintage in full extension for 8 weeks. Boutonniere deformity: Flexion deformity of the proximal interphalangeal joint this is due to interruption or stretching of the central slip of the extensor tendon where it inserts into the base of the middle phalanx. The lateral slips separate and the head of the proximal phalanx thrusts through the gap like a button through a buttonhole.

•Tendon lesions: Swan neck deformity: This is the reverse of boutonniere deformity, the proximal interphalangeal joint is hyper-extended and the distal interphlangeal joint flexed. This usually results from imbalance between flexor versus extensor action at the proximal interphalangeal joint. •Joint disorders: Rheumatoid arthritis, juvenile chronic arthritis,psoriatic arthritis, systemic lupus erythematosus,scleroderma, gout and trauma to the joint can lead to a variety of deformities like mallet finger,boutonniere and swan neck deformity.

•Neuromuscular disorders: Spastic disorders like cerebral palsy may result in Intrinsic plus deformity also thumb in palm deformity. Flaccid disorders like poliomyelitis, peripheral nerve lesions also lead to a variety of deformities among which is the intrinsic minus (claw hand) hand that shows wasting of the small muscles of the hand and clawing with extension of the metacarpophalangeal joints and flexion of the interphalangeal joint.

Tenosynovitis The extensor retinaculum contains six compartments which transmit tendons lined with synovium. Tenosynovitis can be caused by overuse, repetitive minor trauma or spontaneously. The resulting synovial inflammation causes secondary thickening of the sheath and stenosis of the compartment.

De Quervain’s disease: Tenosynovitis of the first extensor compartment containing the abductor pollicis longus and extensor pollicis brevis. Clinically the patient complain of pain on the redial side of the wrist, sometimes there is swelling over the distal end of the radius and the tendon sheath feels thick and hard. Tenderness is most severe at the tip of the styloid radius.

De Quervain’s disease: The pathognomonic sign is elicited by Finkelstein’s test where the examiner places the patient’s thumb across the palm in full flexion, then turning the wrist sharply into adduction. In a positive test this is acutely painful. Differential diagnosis includes arthritis of the base of the thumb, scaphoid non union. Treatment in early cases is in the form of splintage, NSAID, local corticosteroids injection. Resistant cases need surgical release of the compartment slitting the thickened tendon sheath.

Other sites of extensor tenosynovitis: Tenosynovitis of the extensor carpi radialis brevis (the most powerful extensor of the wrist) or extensor carpi ulnaris cause pain directly over its relative compartment. Usually rest and corticosteroid injection are effective.

Flexor Tendinitis: Except for specific inflammatory disorders such as rheumatoid arthritis flexor tendons are rarely affected. Flexor carpi radialis tendinitis causes pain alongside the scaphoid tubercle, symptoms are reproduced by resisted wrist flexion. Flexor carpi ulnaris can become inflamed near its insertion in to the pisiform. Treatment consist of rest, NSAID or local steroid injection.

Stenosing tenovaginitis (trigger finger) A flexor tendon may become entrapped at its entrance to the fibrous flexor sheath, on forced extension it passes the constriction with a snap (triggering). The cause is thickening of the fibrous flexor sheath following trauma or unaccustomed activity, also it can occur in rheumatoid patients, diabetics and in gout. When the finger is flexed it remains bent at the proximal interphalangeal joint, it extends with a snap. A tender nodule can be felt in front of the metacarpophalangeal joint. Treatment: early cases may be cured by local injection of corticosteroids in the tendon sheath. Late cases need surgical release of the fibrous sheath till the tendon moves freely.

Swellings around the wrist Ganglion cysts: The ganglion cyst is the most common swelling around the wrist. It arises from leakage of synovial fluid from a joint or tendon sheath and contain a viscous fluid. Most common on the dorsal surface of the wrist. Clinically the swelling is usually painless. It is well defined, cystic, not tender. Treatment is usually not necessary, it may disappears spontaneously. Surgical excision is indicated if the swelling is painful or pressing a nearby nerve.

Compound palmar Ganglion Chronic inflammation distends the common flexor tendon sheath both above and below the flexor retinaculum. Rheumatoid arthritis and tuberculosis are the commonest causes. The synovial membrane becomes thick and villous. The amout of fluid increases and may contain fibrin particles. The tendons may fray and rupture. Clinically it is painless but pressure over the median nerve may elicit paraethesia. The swelling is hour glass in shape bulging above and below the flexor retinaculum, fluid can be pushed from one part to the other. Treatment: If the condition is tuberculous, general treatment is begun, the content of the sac is evacuated, streptomycin is instilled and wrist splint applied. Flexor sheath is excised if these measures fails, also it is excised in RA.

Carpal Tunnel Syndrome Median nerve compression under the flexor retinaculum. It is more common in females, between 40 and 50 years. In younger patient other factors are commonly present such as pregnancy, rheumatoid arthritis, gout. Clinically: Pain and paraethesia occur in the distribution of the median nerve in the hand. Patient usually wake up with burning pain, tingling and numbness. Sensory symptoms can often be reproduced by percussion over the median nerve (Tinel’s sign) or by holding the wrist fully flexed for a minute or two (Phalen’s test). In late cases there is wasting of the thenar muscles, weakness of thumb abduction and sensory dulling in median nerve distribution.

INABILITY TO ABDUCT THE THUMB

Carpal Tunnel Syndrome Treatment: Light splint that prevent wrist flexion help those with night pain or with pregnancy. Local corticosteroid injection in the carpal canal provides temporary relief. Surgical division of the transverse carpal ligament (the flexor retinaculum) provides cure.

Injuries of the wrist Colles’ fracture: It is the most common of all fractures in older people. The patient is usually a post menopausal woman. Mechanism of injury: Fall on the out stretched hand. It occurs within 2 cm of the articular surface and may extend into the distal radio-carpal joint or the distal radio-ulnar joint. The distal fragment shows: Dorsal angulation (Dinner fork deformity), dorsal displacement, radial angulation, radial displacement, impaction (shortening) and There is often an accompanying fracture of the ulnar styloid, which may signify avulsion of the TFC insertion.

Clinical features: There is a dinner fork deformity, with prominence on the back of the wrist and a depression in front with local tenderness and pain on wrist movements. X-ray: There is a transverse fracture of the radius at the corticocancellous junction, and often the ulnar styloid process is broken off. The distal fragment is impacted into radial and backwards tilt. Sometimes it is comminuted or severely crushed..

Treatment: Undisplaced fractures (or only very slightly displaced), cast is applied below elbow (if ulnar styloid is intact) or above elbow if there is fracture ulnar styloid. If the patient’s wrist is markedly swollen a splint is first applied till the sweling has resolved, then cast is applied. Displaced fractures must be reduced under anaesthesia then cast is applied either below or above elbow according to the presence of ulnar styloid fracture. X-rays are taken after one week, redisplacement is not uncommon to which re-reduction is done. The fracture usually unites in about 6 weeks.

Comminuted Colles’ fractures can not be treated sufficiently with cast immobilization, this is supplemented by K-wire fixation. Cast and wires are removed after 6 weeks. Severely comminuted fractures external fixator is needed.

Complications: Early Circulation in the fingers should be checked; cast may need to be split. Nerve injury is rare, but compression of the median nerve in the carpal tunnel is fairly common. Mild symptoms may resolve by elevation and release of cast. Persistent and severe symptoms require carpal tunnel release. Reflex sympathetic dystrophy is common but usually it does not progress to full picture of Sudek’s atrophy. This is avoided by finger exercises. Triangular fibrocartilage complex (TFCC) injury: As the distal radius displaces dorsally, the TFCC is damaged.

Late Malunion is common either because reduction was not complete or because displacement within the plaster was overlooked. Osteotomy to correct the deformity is needed if there is painful movement. Delayed union and non union of the distal radius are rare, but the ulnar styloid process often joins by fibrous tissue only and remains painful for several months. Stiffness of the shoulder, elbow and fingers from patient neglect is a common complication that can be avoided by exercises. Tendon rupture of extensor pollicis longus occasionally occurs a few weeks after an apparently trivial undisplaced fracture of the lower radius.

SMITH FR

ENCHONDROMA WITH PATHOLOGICAL FRACTURE

MULTIPLE ENCHONDROMATA The hand is the commonest site