Elbow fracture (coronoid, olecranon, radial head)

Question 1

What is cubitus valgus vs varus?

Answer 1

cubitus valgus (increased carrying angle)

cubitus varus (decreased carrying angle)

Question 2

What are the bony landmarks of the elbow?

Answer 2

olecranon and the two epicondyles which form an equilateral triangle in the flexed position

Question 3

What is the normal range of elbow movement ?

Answer 3

Flexion/extension - 0 to 150 degrees

Pronation/supination - 90degrees (mid-prone position is usually taken as 0)

Question 4

Which nerve roots are responsible for elbow flexion and extension?

Answer 4

• C6 – elbow flexion, wrist extension
• C7 – elbow extension, wrist flexion

Question 5

What is the most common elbow fracture?

Answer 5

Supracondylar, occurs mostly in children

Question 6

What is the most common mechanism for elbow dislocation?

Answer 6

This is usually produced by a fall on the hand with the elbow partially flexed.

Question 7

What is a common mechanims for fracture dislocation of the elbow?

Answer 7

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

Question 8

What type of elbow fracture is shown? What is the mechanism of injury?

Answer 8

Supracondylar fracture of the humerus - lower fragment is typically displaced and rotated backwards

MOI: childhood fall on an outstretched hand

Question 9

How do supracondylar fractures present?

Answer 9

• Considerable swelling
• Elbow held in semi-flexed position
• Crepitus on movement

Question 10

What are the complications of supracondylar fractures?

Answer 10

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.

Question 11

What is the management of supracondylar fractures?

Answer 11

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

Question 12

How long after manipulation should you monitor someone with supracondylar fracture?

Answer 12

24hrs to monitor for limb ischaemia

Question 13

What are the warning signs for limb ischaemia in supracondylar fractures? What are the complications of this?

Answer 13

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

Question 14

What is shown?

Answer 14

Volkmann’s contracture

Question 15

What is the management of a supracondylar fracture which is unstable after manipulation and collar/cuff positioning?

Answer 15

1. Immobilisation in extension if unstable in flexion
2. Traction e.g. Dunlop traction for supracondylar fracture
3. Internal fixation

Question 16

What is the mechanims of injury of epicondyle fractures?

Answer 16

Childhood fall on the arm

Question 17

Describe medial epicondyle fractures.

Answer 17

Medial epicondyle usually avulsed by the medial ligament –> becomes trapped in medial side of elbow joint –> visible on lateral XR

Question 18

Which type of epicondylar fracture is this?

Answer 18

Medial epicondylar avulsion fracture

Question 19

What is the management of medial epicondylar fractures?

Answer 19

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.

Question 20

Which epicondylar fracture invovles a larger piece of bone?

Answer 20

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.

Question 21

What is the management of lateral epicondyle fractures?

Answer 21

Fragment usually needs pinning back in position to avoid non-union and later deformity due to growing epiphysis

Question 22

What are the complications of lateral condyle fractures?

Answer 22

• Non-union
• Deformity - causing cubitus valgus
• Ulnar nerve palsy - in later life, if cubitus valgus develops

Question 23

Who is usually affected by T shaped/intercondylar fractures of the humerus?

Answer 23

Usually occurs in adults due to a combination of supracondylar fracture and vertical break between two condyles

Question 24

What is the management of T-shaped and intercondylar fractures of the humerus?

Answer 24

Open reduction and rigid internal fxation

Early mobilisation may be permitted after this

Question 25

What is the mechanism of injury for fractures of the radial head?

Answer 25

Abduction injuries in which the head is driven against the capitulum and medial ligament is strained

Question 26

What is shown ? What are the clinical features of this fracture type?

Answer 26

Fracture of the radial head

• Swollen elbow
• Pain esp on pronation and supination
• Local tenderness over radial head and on medial side

Question 27

What is the management of radial head fractures?

Answer 27

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

Question 28

What is the mechanism of injury in olecranon fractures?

Answer 28

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

Question 29

What is shown?

Answer 29

Olecranon fracture - proximal fragment is pulled away from the distal by the triceps

Question 30

What is the management of olecranon fractures?

Answer 30

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

Question 31

What nerve pasly occurs when the median nerve becomes damaged at the elbow?

Answer 31

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

Question 32

What is the significance of a posterior elbow effusion?

Answer 32

Posterior elbow joint effusion is always indicative of a fracture or pathology on flexed radiograph.