Chapter 30- Fractures of the humerus and elbow Flashcards
What are the two necks of the humerus called and where are fractures more likely seen?
- Anatomical neck: edge of the articular surface or old physeal scar
- Surgical neck: demarcation of the tuberosities from the shaft
- Fractures more commonly seen through the surgical neck
What type of fractures are seen at the head/ articular surface of the humerus?
- Head splitting or impression fractures
- Fractures through the anatomical neck causing articular surface detachment (risk of avascular necrosis)
Fracture of the greater and lesser tuberosities is often associated with which other injury
-Shoulder dislocation
Fractures of the proximal humerus are seen in young people with good bone stock or old people with osteoporotic bone, what is the typical history/ presentation in each group?
- Young people: high energy injury, other associated injuries or multiple fractures. Often present with complex fractures of the proximal humerus involving more than one anatomical segment
- Old people: low energy injuries (simple fall). Fractures are relative stable.
What are the examination findings in patients with fractures of the proximal humerus
- Marked local swelling and bruising in the high energy injuries
- marked bruising, often down the length of the inner aspect of the upper arm, in low energy injuries
- Inability to move the arm
- 5% will have clinical nerve injuries
Which three Xray views should be requested in a proximal humerus fracture?
- AP
- Lateral scapula
- Modified axillary views
In elderly patients, what is the cause of the apparent inferior subluxation of the humeral head in proximal humeral fractures?
Inhibition of the rotator cuff by pain which allows the head to sag
Treatment of undisplaced fractures of the proximal humeral head
- Shoulder immobilizer or a body bandage and collar and cuff
- Followed with weekly Xrays
- Analgesia and sleeping tablets
- usually start gentle pendulum and range of motion at three weeks
What is the definition of a displaced fracture of the head of the humerus?
- More than 1 cm displacement or 45 degrees of angulation between the fragments
- For younger patients it is now thought to be 0.5 cm and 30 degrees
Treatment of fracture of the head/articular surface of the humerus?
- Young patient: Open reduction and internal fixation
- Old patient: hemi-Arthroplasty to replace the humeral head. If patient not fit for surgery then shoulder placed in immobiliser until pain is settled and then gentle active movement commenced
Treatment of displaced fracture of the humeral tuberosities?
-Surgically reduced and fixed
When should a fracture of the surgical neck of the humerus have open reduction and internal fixation?
If irreducible or if associated with a fracture of the head and or tuberosities
Where does the radial nerve run (in relation to the humerus)
The radial nerve winds its way around the shaft of the humerus. It lies in close contact to the posterior aspect of the mid-shaft of the humerus (In the spiral groove)
What is the typical history in a fracture of the shaft of the humerus?
- Direct force: motor vehicle, gunshot, direct blow to arm
- Indirect force: Twisting arm while falling on hand, forced external rotation
What are the examination findings in a fracture of the shaft of the humerus?
- Painful, swollen upper arm
- Inability to lift the arm
- Always check for radial nerve function
Which plaster techniques can be used to treat humeral shaft fractures
-Hanging casts
-U- Slabs
Use the same philosophy of using gravity to align the fracture
What are the surgical means of immobilization of a humeral shaft fracture?
Plating, nailing and external fixation
When is surgical immobilisation done in a humeral shaft fracture?
- Polytrauma
- Patients who will be recumbent
- Severe chest trauma
- Open fractures
- Brachial plexus or nerve injury
- Concomitant injury of the shoulder, elbow or forearm
which groups of people usually suffer from supracondylar fractures?
Children and old people suffering from osteoporosis
What is the typical fracture pattern when young people suffer from supracondylar fractures?
-Additional vertical split between the condyles(T or Y intercondylar fractures)
Typical history of a supracondylar or intercondylar fracture
- Low energy fall on outstretched hand
- high energy vehicular or gunshot injury
Examination findings of supracondylar or intercondylar fracture?
- marked swelling, bruising around elbow region
- Inability to move the elbow joint
- Must exclude and avoid a compartment syndrome
What investigations should be done in a supracondylar or intercondylar fracture
- AP and lateral xrays to demonstrate fractures
- Oblique or traction views to plan surgery
- CT scans when the fracture cannot be adequately visualised
Treatment of supracondylar or intercondylar fracture
-Adults: open reduction and internal fixation
If not possible, manipulated and treated in a shoulder immobiliser (Bag of Bones technique); or modified Dunlop traction
-Total elbow replacements for non-reconstructable fractures
Typical history of a condylar fracture
Fall on the arm with a varus or valgus force
Findings on examination of a condylar fracture
- pain, tenderness and fullness anterior to the elbow joint
- reduced range of movement of the elbow joint
Treatment of condylar fractures
- undisplaced: Backslab for 4-6 weeks
- Displaced- Open reduction and internal fixation
What injury is Medial epicondyle avulsion usually associated with?
Elbow dislocation
Typical history of epicondylar fractures
- Forcible muscle contraction of the forearm, or excessive varus/ valgus stress
- pain over the epicondyle, and on contraction of the forearm muscles
Findings on examination of epicondylar fractures
- Tenderness, swelling and bruising over the medial and lateral epicondyle
- Weakness of the forearm flexors and extensors
- Decreased range of elbow movement if the epicondyle is trapped in the joint
Treatment of epicondylar fractures
-Displacement of > 5mm: Open reduction and fixation
What is the most common direction of elbow dislocation
-Posterior dislocation, forearm bones displacing posterior to the humerus, often accompanied with either lateral or medial displacement
What is divergent dislocation of the elbow
Forearm bones part company with one anterior and one posterior to the humerus OR one medial and one lateral to it.
What is the important implication of a divergent dislocation?
The interosseus membrane has been torn as a result of the distal humerus being driven forcibly between the radius and ulna- high likelihood of neurovascular involvement
what three joints make up the ‘elbow joint’
-Ulna humeral
Radio humeral
Proximal radio-ulnar
Typical history of dislocation of elbow joint
- Fall on semi-extended arm, will push forearm posteriorly
- Patient will complain of pain over the elbow joint and inability to flex/ extend the elbow
Examination findings in dislocation of elbow joint
- obvious deformity around the elbow region, forearm appearing shortened
- Distortion of the normal bony landmarks around the elbow
- Limitation of all movement at the elbow joint
- Neurovascular examination is essential
Treatment of elbow dislocations
- Reduction under anaesthesia
- Medial or lateral displacement corrected and then traction applied in semi-flexed position until clunk heard and allows full passive extension and flexion
- Post reduction Xray
- Backslab for 10 days –> gradual range of motion in shoulder immobilizer
- 2 weeks of indocid to prevent heterotopic ossification
What are the two basic functions of the olecranon
- Insertion of triceps tendon
- Articulates with trochlea of humerus
Typical history of olecranon fracture
- Direct blow to the elbow
- Penetrating injuries of the elbow
- Fall on hand with triceps contracted
- Patient complains of pain and swelling over the area, and an inability to actively extend the elbow
Findings on examination of olecranon fracture
- Tenderness and swelling over the tip of the olecranon and the proximal ulna
- Loss or limitation of active elbow extension
- Gap may be palpable over the fracture site
Treatment of olecranon fracture
Open reduction and internal fixation with tension band wiring tecnique or a plate is the method of choice
Typical history of fractures of the radial head
fall on the outstretched hand with a valgus force
Findings on examination of a fracture of the radial head
- swelling around the elbow
- pain and tenderness over the radial head
- Flexion/ extension of the elbow is painful but possible
- pain exacerbated by pronation and supination of the forearm which are severely limited
What xray views should be requested in fracture of the radial head
Oblique/ radial head views
When can a fracture of the radial head be treated conservatively with splinting and analgesia?
Rule of threes:
If the fracture involves less than 1/3 of the head, 30 degrees of tilt or 3 mm of displacement
What are the surgical options for fracture of the radial head
Internal fixation- use of mini fragment screws
Excision of the head/ radial head replacement
When should excison of the radial head be done in a fracture of the radial head?
Severely comminuted fractures which cannot be reconstructed for fixation and there is no elbow dislocation nor associated forearm/ wrist injury
Treatment of fractures of the radial neck
- Minimal angulation of the head in adults can be accepted and treated conservatively
- Angulation of >30 degrees should be corrected- usually surgically, and the head fixed to the neck with either small screw/ plate
