elbow fractures and instabilities Flashcards
compare the locations of an extra-articular vs intra-articular distal humerus fracture
- extraarticular - supracondylar
- intraarticular - lateral or medial epicondyle, intercondylar, capitellum
what is the MOI of paediatric elbow fractures?
fall on outstretched hand
Describe a supracondylar fracture
-most common in children aged 5-10
-MOI= fall on hand with elbow extension
-MOI2 - direct anterior force against a flexed elbow
-very uncommon in adults
what are neurovascular complications from a supracondylar fracture?
-injury to the brachial artery
-compartment syndrome
-volkmanns ischaemic contracture (due to inadequate treatment of compartment syndrome0 - shortening of forearm flexors
-median nerve damage
what are other complications of supracondylar fractures other then neuromuscular?
-myositis ossificans - in brachialis region
-cubitus varus - malunion
what is the symptoms associated with a median nerve injury?
-ape hand
-hand of benediction
-tinel sign (tapping median nerve - imitates symptoms in hand)
describe an intracondylar fracture in children (lateral vs medial condyle)
-lateral condyle - common in children
-medial condyle - more common in early teens & males
describe a radial head and neck fracture in children
-1-5% of paediatric elbow fractures
-radial head subluxation can also occur
describe olecranon fractures in children
-uncommon
-can occur with radial head and neck fractures
how are displaced vs non displaced supracondylar fractures managed?
-non displaced - long arm splint and progress to cast w/ elbow at 90 deg flexion & forearm nuetral
-displaced - surgery to reduce and fix followed by splint or cast for 3-4 weeks
how are lateral condyle fractures managed?
splint / cast for 6 weeks
how are medial condyle fractures managed if they require surgery?
-shorter splint / cast time
-1-2 weeks
how many degrees displacement of the radial head requires surgery?
- more than 30
how are intercondylar fractures managed in adults?
-undisplaced or unicondylar fractures generally managed conservatively
-displaced or comminuted fractures can require surgery to fix
-difficult to fix as many bone fragments & loss of mineral density
-donjoy brace in flexion initially
what are examples of complications post interconydlar fracture in adults?
-elbow stiffness - asp loss of full extension
-early mobilisation generally recommended
-long term risk of OA if fracture extends into the elbow joint
-ulnar nerve palsy
what are some symptoms associated with ulnar nerve damage?
-muscle weakness in hand
-decreased grip strength
-muscle wasting - hypothenar eminence
-numbness, pain and tingling in hand
-clawing of 5th and 5th digits
what age groups most commonly suffer from a olecranon fracture?
-patient aged 50+
-if younger- high trauma injury
what are the causes of a fractured olecranon?
-direct - fall on point of elbow
-indirect - strong triceps contraction causing avulsion
how are hairline or undisplayed olecranon fractures managed?
-POP / donjoy cast in flexion
-early mobilisation in brace with avoidance of full flexion
how are displaced olecranon fractures managed?
- ORIF
what is the MOI for a dislocated elbow & which direction of dislocation is most common?
MOI= Fall with outstretched arm In extension
-posterolateral direction most common
if there is an anterior dislocation of the elbow, what can also be associated with it?
a fracture
how are dislocated elbows managed?
-reduce (correct misalignment)
-early mobilisations, work into extension
-collar and cuff
what are examples of complications post elbow dislocation?
-joint stiffness
-instability
-heterotrophic ossification (formation of mature lamellar bone in extra osseous tissue)
-recurent dislocation
-nerve damage eg medial - ulnar - but this is uncommon
what is the terrible triad of the elbow?
-posterior lateral elbow dislocation
-radial head fracture
-coronoid fracture
how is the ‘terrible traid’ repaired / managed?
- restore the lateral column (radial head and radial collateral ligament) of the elbow
-avoid the development of posterior lateral instability
what is the MOI for a radial head fracture?
- fall on outstretched arm with wrist extended and forearm pronated
how are simple and non displaced radial head fractures managed?
- non operative treatment
-sling for comfort
-keep moving - flex/ext of elbow, and as pain settles - sup and pro
how are displaced radial fractures managed?
- reduce and apply stable fixation
- for severe communication fractures, may need radial head replacement to prevent instability
what are the 2 main ligaments of the elbow?
-lateral collateral ligament
-medial collateral ligament
Describe an ulnar collateral ligament sprain
-also called medial ulnar collateral ligament
-acute injury or repeated valves stresses due to throwing eg javelin
-acute or chronic onset
-valgus laxity
describe the symptoms associated with acute or chronic ulnar collateral ligament sprain?
- acute - hear a ‘pop’
- pain with reduced throwing power
what is the primary structure resisting valgus stress?
-UCL/ medial ulnar collateral ligament
how does throwing affect the UCL?
-places repetitious high valgus stress on the medial aspect of the elbow joint and UCL
-produces microscopic tears and could eat to rupture of weakened ligament overtime
what can ligamentous insufficiency lead to?
-degenerative or traumatic arthritis w/ osteophytic formation
what are signs and symptoms of UCL sprain?
-medial elbow pain generally on activity
-localised tenderness over ligament
-pain w/ valgus stress test + laxity seen
-may or may not have ulnar nerve injuries
what can posterolateral rotatory instability (PLRI) caused by?
-a weak lateral collateral ligament complex, esp a weak lateral ulnar collateral ligament
what happens to the proximal radius and ulna in posterolateral rotaory instability?
-proximal radius and ulna externally rotate together as a unit in relation to the humerus causing posterior subluxation or dislocation of the radial head relative to the capitellum
what are the signs & symptoms of posterolateral rotatory instability?
-generally younger people and females
- may or may not have lateral elbow pain
-often full range of motion
-positive pivot shift test / push up test etc
-may have various laxity
what are the aims of physiotherapy for elbow fracture / instability management ?
-guided by orthopaedic team
-provide patient w/ pain free, stable functional elbow
-mobilise ASAP after trauma - active assisted, active ROM
-fitting of donjon brace/ splint/ support
-ROM & strength in unaffected joints eg wrist and shoulder
-manual therapy as indicated w/ grades guided by healing stage
what is the motion arc for elbow flexion?
30-120deg
what is the motion arc for pronation & supination?
50 deg for pro and sup
what are examples of early protected ROM exercises for lateral instability eg for pro/sup and flex/ext?
-supine overhead position with the shoulder flexed to 90 deg
- for pro/sup - forearm resting on forehead, gentle active assisted supination & pronation is performed
-flex/ext- forearm is held in full pronation and gentle active and active assisted elbow flexion to full range & elbow extension (not past 30deg)
what does stage 1 of elbow rehab involve?
-protected ROM to active ROM as healing progresses
what does stage 2 of elbow rehab involve?
-start strengthening & weight bearing (around 6 weeks +)
what does stage 3 of elbow rehab involve?
-progress strength - add speed etc
-pylometrics
-throwing training if required
