Elbow fracture (coronoid, olecranon, radial head) Flashcards
What is cubitus valgus vs varus?
cubitus valgus (increased carrying angle)
cubitus varus (decreased carrying angle)
What are the bony landmarks of the elbow?
olecranon and the two epicondyles which form an equilateral triangle in the flexed position
What is the normal range of elbow movement ?
Flexion/extension - 0 to 150 degrees
Pronation/supination - 90degrees (mid-prone position is usually taken as 0)
Which nerve roots are responsible for elbow flexion and extension?
- C6 – elbow flexion, wrist extension
- C7 – elbow extension, wrist flexion
What is the most common elbow fracture?
Supracondylar, occurs mostly in children
What is the most common mechanism for elbow dislocation?
This is usually produced by a fall on the hand with the elbow partially flexed.
What is a common mechanims for fracture dislocation of the elbow?
Injury sustained by a blow to the elbow held hanging out of a car window i.e. ‘side-sweep’
Condyles of humerus, radial head or most commonly the olecranon can become fractured
What type of elbow fracture is shown? What is the mechanism of injury?
Supracondylar fracture of the humerus - lower fragment is typically displaced and rotated backwards
MOI: childhood fall on an outstretched hand
How do supracondylar fractures present?
- Considerable swelling
- Elbow held in semi-flexed position
- Crepitus on movement
What are the complications of supracondylar fractures?
Damage to brachial artery - damaged if the elbow is flexed before the fracture is reduced
‘Gunstock’ deformity - malunion
NB:Nerve injuries are uncommon but median and ulnar palsies may occur.
What is the management of supracondylar fractures?
Manipulation under anaesthesia - elbow is kept flexed to about 60 degrees and the epicondyles are held between
the operator’s fingers whilst fragment is moved downwards and forwards. Serial XR taken to confirm position
Collar and cuff sling - epicondyles must be held level otherwise the frasture may unite with a tilt; this is held against the chest. Elbow should not be flexed over 90 degrees as swelling may impair distal circulation
How long after manipulation should you monitor someone with supracondylar fracture?
24hrs to monitor for limb ischaemia
What are the warning signs for limb ischaemia in supracondylar fractures? What are the complications of this?
Pain in the forearm flexor region and particularly on passive extension of the fingers is a warning sign of ischaemia of the forearm muscles. Elbow must be extended if this occurs and the artery explored.
If untreated –> Volkmann’s ischaemic contracture
What is shown?
Volkmann’s contracture
What is the management of a supracondylar fracture which is unstable after manipulation and collar/cuff positioning?
- Immobilisation in extension if unstable in flexion
- Traction e.g. Dunlop traction for supracondylar fracture
- Internal fixation
What is the mechanims of injury of epicondyle fractures?
Childhood fall on the arm
Describe medial epicondyle fractures.
Medial epicondyle usually avulsed by the medial ligament –> becomes trapped in medial side of elbow joint –> visible on lateral XR
Which type of epicondylar fracture is this?
Medial epicondylar avulsion fracture
What is the management of medial epicondylar fractures?
Manipulation - abduction of the elbow and attemps to draw out the fragment by extending the wrist and fingers
Surgery - if the above fails. Fragment may be stable or may need to be pinned.
Which epicondylar fracture invovles a larger piece of bone?
Lateral epicondyle fractures look smaller than they actually are on radiographs because in children ossified epiphysis visible is only a small part of a large fragment.
What is the management of lateral epicondyle fractures?
Fragment usually needs pinning back in position to avoid non-union and later deformity due to growing epiphysis
What are the complications of lateral condyle fractures?
- Non-union
- Deformity - causing cubitus valgus
- Ulnar nerve palsy - in later life, if cubitus valgus develops
Who is usually affected by T shaped/intercondylar fractures of the humerus?
Usually occurs in adults due to a combination of supracondylar fracture and vertical break between two condyles
What is the management of T-shaped and intercondylar fractures of the humerus?
Open reduction and rigid internal fxation
Early mobilisation may be permitted after this
What is the mechanism of injury for fractures of the radial head?
Abduction injuries in which the head is driven against the capitulum and medial ligament is strained
What is shown ? What are the clinical features of this fracture type?
Fracture of the radial head
- Swollen elbow
- Pain esp on pronation and supination
- Local tenderness over radial head and on medial side
What is the management of radial head fractures?
Depends on type of fracture and range of motion.
Sling support and early mobilisation - only if minor cracks or undisplaced fractures
Surgical -
- If comminuted the radial head should be excised at earliest opportunity as this will restrict rotation - NB: not excised in children as his is the epiphysis
- If large fragments, these may be fixated with tiny screws or wires
- In severe comminution with radius displacing upwards, a radial head prosthesis may be needed to restore joint alignment
What is the mechanism of injury in olecranon fractures?
May occur as part of a fracture dislocation of the elbow or isolated injury. Proximal fragment is usually pulled away from the distal fragment by the triceps muscle
What is shown?
Olecranon fracture - proximal fragment is pulled away from the distal by the triceps
What is the management of olecranon fractures?
Open reduction and internal fixation - using long screw or tension band technique, usually full movement can be achieved
NB: in frail patients the fracture may be left and mobilised to avoid stiffness, although weakness will likely remain on extension e.g. when reaching a shelf above shoulder height
What nerve pasly occurs when the median nerve becomes damaged at the elbow?
Ape hand= cannot move the thumb away from the rest of the hand, FDP not functional
Sign of Benediction = damage to median nerve at forearm, FDP still functional
What is the significance of a posterior elbow effusion?
Posterior elbow joint effusion is always indicative of a fracture or pathology on flexed radiograph.
