Injuries of upper arm and

elbow
Dr. AMMAR TALIB AL-YASSIRI
COLLEGE OF MEDICINE/ BAGHDAD
UNIVERSITY
 Learning outcomes
• Describe the mechanism of injury
• Describe the clinical features
• Explain the treatment
• Recognize complication
FRACTURES OF THE PROXIMAL HUMERUS

• Common after middle age

• most of the patients are osteoporotic,
postmenopausal women
• Mechanism of injury: fall on the out-stretched
arm
• Classification and pathological anatomy
– Neer’s classification
head, greater tuberosity, lesser tuberosity,
– four major segments and shaft.
– Based on the number of displaced fragments, with
displacement defined as greater than 45 degrees of
angulation or 1 cm of separation.
Thus, however many frac- ture lines there are, if the fragments are undisplaced it is regarded as a
one-part fracture; if one segment is sep-
• Clinical features:
– pain may not be severe.
– large bruise on the upper part of the arm is suspicious.
– Signs of axillary nerve or brachial plexus injury must be
looked for
• X-ray:
– In elderly
– In younger patients,
– Axillary and scapular-lateral views should always be
taken, to exclude dislocation of the shoulder.
– The advent of three-dimensional CT reconstruction
• Treatment
– MINIMALLY DISPLACED FRACTURES
• the arm rested in a sling until the pain subsides (1-2 wks),
• gentle passive movements of the shoulder.
• Once the fracture has united(usually after 6 weeks) active
exercises
– TWO-PART FRACTURES
• Surgical neck fractures
• Greater tuberosity fractures
• Anatomical neck fractures
– THREE-PART FRACTURES
– FOUR-PART FRACTURES
– FRACTURE-DISLOCATION
ORIF
• Complications
– Vascular injuries and nerve injuries:
– Avascular necrosis:
– Stiffness of the shoulder:
– Malunion:
FRACTURES OF THE PROXIMAL HUMERUS IN CHILDREN

• At birth, the shoulder may be dislocated or

the proximal humerus fractured. Diagnosis is
difficult and a clavicular fracture or brachial
plexus injury should also be excluded.
• In infancy, there may be Salter–Harris type I
injury of the physis; perfect reduction is not
so important and a good outcome is usual.
• In older children,
– metaphyseal fractures or Type II physeal fractures
occur.
– Pathological fractures are not unusual,
FRACTURED SHAFT OF HUMERUS
• Mechanism of injury:
– A fall on the hand may twist the humerus,
causing a spiral fracture.
– A fall on the elbow with the arm abducted
exerts a bending force, resulting in an oblique
or transverse fracture.
– A direct blow to the arm causes a fracture
which is either transverse or comminuted.
– Fracture of the shaft in an elderly patient
may be due to a metastasis.
• Pathological anatomy:
– With fractures above the deltoid insertion
– With fractures lower down,
– Injury to the radial nerve is common, though fortunately
recovery is usual.
• Clinical features: Test the function by extending the MCP joints (i.e
extending the fingers ) (wrist extension may be
– painful, normal because Extensor carpi radialis sometimes
– bruised takes its innervation in a site proximal to the injury
– swollen.
– test for radial nerve function before and after treatment.
• X-ray: shows site, line (transverse, spiral or
comminuted) and displacement. Signs of pathological
fracture should be sought for.
Treatment:
• ‘hanging cast’ replaced after 2–3 weeks by
• a short (shoulder to elbow) cast or a functional
polypropylene brace (6 weeks).
• The wrist and fingers are exercised from the
start.
• Pendulum exercises of the shoulder are begun
within a week
• active abduction is postponed until the fracture
has united (about 6 weeks for spiral fractures
but often twice as long for other types)
It is well to remember

(a) that the complication rate after internal fixation of the humerus
is high

(b) that the great majority of humeral fractures unite with non-
operative treatment.

(c) There is no good evidence that the union rate is higher with
fixation (and the rate may be lower if there is distraction with
nailing or periosteal stripping with plating).
OPERATIVE TREATMENT

• indications for surgery:

– severe multiple injuries
– an open fracture
– segmental fractures
– displaced intra-articular extension of the fracture
– a pathological fracture
– a ‘floating elbow’ (simultaneous unstable humeral
and forearm fractures)
– radial nerve palsy after manipulation
– non-union
– problems with nursing care in a dependent person.
Complications

• EARLY:
– Vascular injury:
– Nerve injury:
• LATE
– Delayed union and non-union:
• excessive traction has been used (a hanging cast must not be
too heavy).
• Segmental high energy fractures and open fractures are
more prone to both delayed union and non-union.
• Intramedullary nailing may contribute to delayed union.
• The treatment of established non-union is operative.
– Joint stiffness: Joint stiffness is common. It can be
minimized by early activity,
Holstein–Lewis fracture
FRACTURES OF THE DISTAL HUMERUS
IN ADULTS
• High-energy injuries which are associated with
vascular and nerve damage.
• There are 3 types of distal humerus fracture
according to AO/ASIF GROUP:
– Type A – an extra-articular supracondylar fracture;
– Type B – an intra-articular unicondylar fracture
(one condyle sheared off);
– Type C – bicondylar fractures with varying degrees
of comminution.
• TYPE A – SUPRACONDYLAR FRACTURES:
– extra-articular fractures are rare in adults.
– displaced and unstable
– Treatment: Open reduction and internal fixation is the treatment of choice
• TYPES B AND C – INTRA-ARTICULAR FRACTURES:
– high-energy injuries with soft-tissue damage.
– severe blow on the point of the elbow
– Swelling is considerable
– elbow is found to be distorted.
– The patient should be carefully examined for evidence of vascular or nerve injury
– X-Ray: T- or Y shaped break, or else there may be multiple fragments (comminution). CT scans can
be helpful in planning the surgical approach.
– Treatment:
• Undisplaced fractures→ back slab with the elbow flexed 90 degrees; movements are commenced after 2
weeks.
• Displaced Type B and C fractures→ ORIF, then early active movements
– Complications
• EARLY:
– Vascular injury
– Nerve injury:
• LATE
– Stiffness:
– Heterotopic ossification
 FRACTURED CAPITULUM
• a rare articular fracture
• occurs only in adults.
• Mechanism of injury: The patient falls on the hand, usually with the
elbow straight. The anterior part of the capitulum is sheared off
and displaced proximally.
• Clinical features:
– Fullness in front of the elbow
– The lateral side of the elbow is tender
– flexion is grossly restricted.
• X-Ray: In the lateral view the capitulum (or part of it) is seen in
front of the lower humerus, and the radial head no longer points
directly towards it.
• Treatment:
– Undisplaced fractures can be treated by simple splintage for 2 weeks.
– Displaced fractures should be reduced and fixed perfectly
 FRACTURED HEAD OF RADIUS
• common in adults but are hardly ever seen in children
• Mechanism of injury: A fall on the outstretched hand
with the elbow extended and the forearm pronated
• Clinical features: tenderness on pressure over the radial
head and pain on pronation and supination.
• X-ray: Three types of fracture are identified and
classified by Mason as:
– Type I An undisplaced vertical split in the radial head
– Type II A displaced single fragment of the head
– Type III The head broken into several fragments (comminuted).
– An additional Type IV has been proposed, for those fractures
with an associated elbow dislocation.
• Treatment:
 -from notes of the previous slide-

• Type I treated by aspiration of the haematoma with

injection of LA this will relieve the pain, the arm rested in
collar and cuff and early active movement is encouraged
• Type II ORIF with small headless screws
• Type III associated soft tissue injury should be sought for:
Rupture of the medial collateral ligament; Rupture of the
interosseous membrane (Essex Lopresti lesion); Combined
fractures of the radial head and coronoid process plus
dislocation of the elbow – the ‘terrible triad’. If any of these
is present, excision of the radial head is contra-indicated
therefore it should be reconstructed or replaced otherwise
head excision is good option if there is no contraindication
Or replaced
FRACTURES OF THE OLECRANON
• Two main types of injury are seen:
• (1) a comminuted fracture which is due to a direct blow or a
fall on the elbow; and
• (2) a transverse break, due to traction when the patient falls
onto the hand while the triceps muscle is contracted.
• further sub-classified into (a) displaced and (b) undisplaced
fractures.
• Clinical features:
• X-ray
• Treatment
– comminuted fracture
– An undisplaced transverse fracture
– displaced transverse
– Displaced comminuted fractures
 Dislocation of the elbow
• most commonly dislocated joint second to
the shoulder
• more in adults than in children
• classified according to the direction of
displacement.
• in 90% of cases the radioulnar complex is
displaced posteriorly or posterolaterally
• Often together with fractures of the
restraining bony processes
Mechanism of injury and pathology
• fall on the outstretched hand with the elbow in
extension.with a valgus force
• If there is no associated fracture, reduction will
usually be stable and recurrent dislocation
unlikely.
• The combination of ligamentous disruption and
fracture of the radial head, coronoid process or
olecranon process (or, worse still, several
fractures) will make the joint more unstable
• surrounding nerves and vessels may be
damaged.
• Side swipe injury occurs, typically, when
a car-driver‘s elbow, protruding through
the window is struck by another vehicle.
– It’s a high energy injury
– Forward dislocation with fractures of any or
all of the bones around the elbow; soft-tissue
damage (including neurovascular injury) is
usually severe.
Clinical features
• The patient supports his forearm with the elbow
in slight flexion.
• Unless swelling is severe, the deformity is
obvious.
• The bony landmarks (olecranon and epicondyles)
may be palpable and abnormally placed.
• the hand should be examined for signs of vascular
or nerve damage
• X-ray:
– confirm the presence of a dislocation
– identify any associated fractures
treatment
• UNCOMPLICATED DISLOCATION
– under anaesthesia.
– The surgeon pulls on the forearm while the
elbow is slightly flexed. With one band,
sideways displacement is corrected, then the
elbow is further flexed while the olecranon
process is pushed forward with the thumbs.
– After reduction, the elbow should be
examined through full range of movement to
see whether it is stable
• The distal nerves and circulation are
checked again.
• an x-ray is obtained
• The arm is held in a collar and cuff with
the elbow flexed above 90 degrees.
• After 1 week the patient gently exercises
his elbow; at 3 weeks the collar and cuff
is discarded
• DlSLOCATION WITH ASSOCIATED FRACTURES
– Coronold process
• A single or comminuted fracture involving more
than 50 % and lf the elbow is unstable after
reduction, then fixation is usually needed.
– Medial epicondyle
• lf displaced, it must be reduced and fixed back in
position.
• The arm and wrist are splinted with the elbow at 90
degrees;
• after 3 weeks movements are begun under
supervision
• Head of radius
– ligament disruption & type ll or III is unstable
injury;
– stability is restored by repair of the ligaments
and restoration of the radial pillar (fracture
fixation or prosthetic replacement)
• Olecranon process
– Open reduction with internal fixation is the
best treatment.
Complications
• EARLY
– Vascular injury
• The brachial artery may be damaged.
• this should be treated as an emergency.
• Splints must be removed and the elbow should be
straightened somewhat.
• If there is no improvement, an arteriogram is performed;
the brachial artery may have to be explored.
– Nerve injury
• The median or ulnar nerve is sometimes injured.
Spontaneous recovery usually occurs after 6-8 weeks.
• LATE
– Stiffness
• Loss of 20 to 30 degrees of extension is not uncommon after
elbow dislocation usually of little functional significance
• Move as soon as possible
– Hetrotopic ossification(myositis ossificans)
• Occur in the damaged soft tissue in front of the joint
• associated with forceful reduction
• If the condition is suspected_ exercises are stopped and the
elbow is splinted in comfortable flexion until pain subsides;
gentle active movements and continuous passive motion are
then resumed.
• Anti-inflammtory drugs may help
• A bone mass can be excised though not before the bone is
fully mature
– Unreduced dislocation
• A dislocation may not have been diagnosed; or
only the backward displacement corrected,
leaving the olecranon process still displaced
sideway
• Up to 3 weeks manipulative reduction .
• Other than this there is no satisfactory treatment
• Open reduction stiffness
• Leave the condition in the hope to gain useful
range of movement
– Recurrent dislocation
• This is rare unless there is a large coronoid fracture or
radial head fracture.
• If recurrent elbow instability occurs, the lateral
ligament and capsule can be repaired or reattached to
the lateral condyle.
• A cast with the elbow at 90 degrees is worn for 4
weeks.
– Osteoarthritis
• Quite common after severe fracture dislocations
• In older patients, total elbow replacement can be
considered
Fractures around the elbow in children

SUPRACGNDYLAR FRACTURES
• Among the commonest fractures in children.
• The distal fragment may be displaced either posteriorly or
anteriorly
• Mechanism of injury
– Posterior angulation or displacement (95%) suggests a
hyperextension injury, usually due to a fall on the outstretched
hand. The humerus breaks just above the condyles. The distal
fragment is pushed backwards and (because the forearm is usually
in pronation) twisted inwards. The jagged end of the proximal
fragment pokes into the soft tissues anteriorly, sometimes injuring
the brachial artery or median nerve.
– Anterior displacement is rare; thought to be due to direct violence
(e.g. a fall on the point of the elbow) with the joint in flexion
Extension injury

Flexion injury
• Classification
– Type I is an undisplaced fracture.
– Type II is an angulated fracture with the
posterior cortex still in continuity.
• IIA - a less severe injury with the distal fragment
merely angulated.
• IIB - a severe injury; the fragment is both
angulated and malrotated.
– Type III is a completely displaced fracture
• Clinical features
– pain
– elbow is swollen;
– with a posteriorly displaced fracture the S-
deformity of the elbow is usually obvious
– It is essential to feel the pulse and check the
capillary return;
– passive extension of the flexor muscles should be
pain-free.
– The wrist and the hand should be examined for
evidence of nerve injury.
S shape deformity
• X-ray
– The fracture is seen most clearly in the lateral view.
– In an undisplaced fracture the ‘fat pad sign’ should raise
suspicions
– In the common posteriorly displaced fracture the fracture
line runs obliquely downwards and forwards and the distal
fragment is tilted backwards and/ or shifted backwards.
– In the anteriorly displaced fracture the crack runs
downwards and backwards and the distal fragment is tilted
forwards.
– An AP View is often difficult to obtain without causing pain
– It may show that the distal Fragment is shifted or tilted
sideways
and rotated usually medially
Fat pad sign
• TREATMENT
– TYPE I UNDISPLACED FRACTURE
• The elbow is immobilized at 90 degrees and
neutral rotation in a light-weight splint or cast and
the arm is supported by a sling.
• It is essential to obtain an x-ray 5-7 days later to
check that there has been no displacement.
• The splint is retained for 3 weeks and supervised
Movement is then allowed
• TYPE II A: FOSTERIORLY ANGULATED FRACTURE -MILD
– the fracture can be reduced under GA by the following step-
wise manoeuvre:
• (l ) traction for 2-3 minutes in the length of the arm with counter-
traction above the elbow;
• (2) correction of any sideways tilt or shift and rotation
• (3) gradual flexion of the elbow to 120 degrees, and pronation of
the forearm, while maintaining traction and exerting finger
pressure behind the distal fragment to correct posterior tilt,
– Following reduction, the arm is held in a collar and cuff; the
circulation checked repeatedly during the first 24 hours. An
x-ray is obtained after 3-5 days to confirm that the fracture
has not slipped.
– The splint is retained for 3 weeks, after which movements
are begun.
• TYPES ll B AND lll ANGULATED AND
MALROTATED OR POSTERIORLY DISPLACED
– These are usually associated with severe swelling,
are difficult to reduce and are often unstable
– The fracture should be reduced under G.A as soon
as possible, by the method described above, and
then held with percutaneous crossed K-wires;
– this obviates the necessity to hold the elbow
acutely flexed.
– Postoperative management is the same as for Type
Il A.
• OPEN REDUCTlON: This is sometimes
necessary for
– a Fracture which simply cannot be reduced
closed;
– an open fracture; or
– a fracture associated with vascular damage
• TREATMENT OF ANTERIORLY DISPLACED
FRACTURES
– The fracture is reduced by pulling on the
forearm with the elbow semiflexed, applying
thumb pressure over the front of the distal
fragment and then extending the elbow fully.
– Crossed percutaneous pins are used if unstable.
– A posterior slab is put and retained for 3 weeks.
– Thereafter, the child is allowed to regain
flexion gradually.
• Complications
– EARLY
• Vascular lnjury :
brachial artery,
– Peripheral ischaemia may be immediate and severe
– the pulse may fail to return after reduction,
More commonly the injury is complicated by forearm
oedema and a mounting, compartment syndrome
– The flexed elbow must be extended and all dressings removed
– if the circulation does not promptly improve,then angiography
(on the operating table if it saves time) is carried out,
– the vessel repaired or grafted and a forearm fasciotomy
performed.
Undue pain plus one positive sign (pain on passive extension of
the fingers, a tense and tender forearm, an absent pulse, blunted
sensation or reduced capillary return on pressing the finger pulp)
• Nerve injury :The radial nerve, median
nerve (particularly the anterior
interosseous branch) or the ulnar nerve
may be injured
– recovery can be expected in 3 to 4 months, If
there is no recovery the nerve should be
explored.
– If it occur after manipulation nerve should be
explored
• LATE
– Malunion is common,
• Backward or sideways shifts are gradually smoothed
out by remodelling
• Forward or backward tilt may limit flexion or
extension, but disability is slight
• Uncorrectcd sideways tilt (angulation) and rotation are
much more important and may lead to varus (or rarely
valgus) deformity
• If it is marked, it will need correction by supracondylar
osteotomy usually once the child approaches skeletal
maturity
• Elbow stiffness and myositis ossifficans
– Extension in particular may take months to
return
– Passive or forced movement is prohibited
– Prevented by Proper rehabilitation