Humerus and Elbow Injuries
Presenter: Dr. Devansh
Gupta
Moderator: Dr. Sanjeev Bhoi
Objectives
Suspect
Identify
Primary Management
Refer for definitive management
Content
Relevant Anatomy
Peripheral Nerve Injuries
• Median
• Radial
• Ulnar
Fractures and dislocations
• Supracondylar fracture Humerus
• Elbow dislocation
• Proximal Humerus
• Shaft Humerus
• Head of Radius
Soft tissue injuries
• Medial and Lateral Epicondylitis
• Biceps Tendon Rupture
Anatomy of the Arm - Bone
Anatomy of the Arm - Muscles
Anatomy of the Arm - Muscles
Biceps Brachii
Nerve supply
• Musculocutaneous Nerve
Action
• Supination of forearm (Forearm flexed)
• Flexion of elbow
• Flexion of arm (Short head)
Anatomy of the Arm - Muscles
Coracobrachialis
Nerve supply
• Musculocutaneous Nerve
Action
• Flexion of arm at shoulder joint
Brachialis
Nerve supply
• Musculocutaneous Nerve (motor)
• Radial Nerve (Proprioceptive)
Action
• Flexion of arm at elbow joint
Anatomy of the Arm - Muscles
Triceps Brachii
Nerve supply
• Radial nerve
Action
• Extension of the elbow joint
Anatomy of the Forearm and Hand- Muscles
Anatomy of the Arm - Arteries
Anatomy of the Elbow - Bones
Anatomy of the Elbow - Bones
Nerves of the Upper Limb
Peripheral Nerve Injuries – Which nerve is
affected?
Attitude and Deformity
Muscle Wasting
Temperature
Reflexes
Motor Examination
Sensory Examination
Median Nerve
Median Nerve
Major Motor Branches
In the Arm
• Nil
In the Forearm
• All flexors of forearm except
• Flexor Carpi Ulnaris
• Medial Half of Flexor Digitorum
Profundus
In the Hand
• Thenar Muscles (3)
• First 2 Lumbricals
Median Nerve
Motor (Muscle) Examination
• Flexor pollicis Longus
Median Nerve
Motor (Muscle) Examination
• Flexor pollicis Longus
• Flexor Digitorum Superficialis and lateral half
of Flexor Digitorum Profundus
Median Nerve
Motor (Muscle) Examination
• Flexor pollicis Longus
• Flexor Digitorum Superficialis and lateral half
of Flexor Digitorum Profundus
Median Nerve
Motor (Muscle) Examination
• Flexor pollicis Longus
• Flexor Digitorum Superficialis and lateral half
of Flexor Digitorum Profundus
• Flexor Carpi Radialis
Median Nerve
Motor (Muscle) Examination
• Flexor pollicis Longus
• Flexor Digitorum Superficialis and lateral half
of Flexor Digitorum Profundus
• Flexor Carpi Radialis
• Muscles of Thenar Eminence
• Abductor Pollicis Brevis (Pen test)
Median Nerve
Motor (Muscle) Examination
• Flexor pollicis Longus
• Flexor Digitorum Superficialis and lateral half
of Flexor Digitorum Profundus
• Flexor Carpi Radialis
• Muscles of Thenar Eminence
• Abductor Pollicis Brevis (Pen test)
• Opponens Pollicis
Median Nerve
Sensory Examination
Specific areas allow unique assessment
of only one nerve
Ulnar Nerve
Major Motor Branches
In the Arm
• Nil
In the Forearm
• Flexor Carpi Ulnaris
• Medial Half of Flexor Digitorum
Profundus
In the Hand
• Hypothenar Muscles
• Palmar interossei
• Dorsal interossei
• Medial 2 Lumbricals
• Adductor Pollicis (Graveyard of Ulnar n)
Ulnar Nerve
Motor (Muscle) Examination
• Flexor Carpi Ulnaris
Ulnar Nerve
Motor (Muscle) Examination
• Flexor Carpi Ulnaris
• Abductor Digiti Minimi
Ulnar Nerve
Motor (Muscle) Examination
• Flexor Carpi Ulnaris
• Abductor Digiti Minimi
• Palmar interossei (PAD) (Card Test)
Ulnar Nerve
Motor (Muscle) Examination
• Flexor Carpi Ulnaris
• Abductor Digiti Minimi
• Palmar interossei (PAD) (Card test)
• Dorsal interossei (DAB) (Egawa Test)
Ulnar Nerve
Motor (Muscle) Examination
• Flexor Carpi Ulnaris
• Abductor Digiti Minimi
• Palmar interossei (PAD) (Card test)
• Dorsal interossei (DAB) (Egawa Test)
• Adductor Pollicis (Froment’s sign)
Ulnar Nerve
Motor (Muscle) Examination
• Flexor Carpi Ulnaris
• Abductor Digiti Minimi
• Palmar interossei (PAD) (Card test)
• Dorsal interossei (DAB) (Egawa Test)
• Adductor Pollicis (Froment’s sign)
• Deformity: Ulnar Claw hand (Low>High)
Ulnar Nerve
Sensory Examination
Specific areas allow unique assessment
of only one nerve
Radial Nerve
Radial Nerve
Major Motor Branches
Before the radial groove
• Long and medial heads of Triceps
After the RG, before crossing the elbow
• Lateral head of Triceps
• Anconeus
• Brachioradialis
• Extensor Carpi Radialis Longus
After crossing the elbow, before piercing supinator
• Extensor Carpi Radialis Brevis
• Supinator
After piercing the Supinator
• Other extensor muscles of forearm and hand
Radial Nerve
Motor (Muscle) Examination
• Triceps brachii
Radial Nerve
Motor (Muscle) Examination
• Triceps brachii
• Brachioradialis
Radial Nerve
Motor (Muscle) Examination
• Triceps brachii
• Brachioradialis
• Extensor Digitorum (Finger Drop)
Radial Nerve
Motor (Muscle) Examination
• Triceps brachii
• Brachioradialis
• Extensor Digitorum (Finger Drop)
• Extensor Pollicis Longus
Radial Nerve
Motor (Muscle) Examination
• Triceps brachii
• Brachioradialis
• Extensor Digitorum (Finger Drop)
• Extensor Pollicis Longus
• Deformity: Wrist Drop
Radial Nerve
Sensory Examination
Specific areas allow unique assessment
of only one nerve
Supracondylar Fracture of the Humerus
Supracondylar Fracture of the Humerus (SCH)
• Most common elbow fracture
seen in children
• Peak age range: 5-6 years
• Can occur in adults – high
velocity injuries
SCH – 2 types
Depending on the direction of displacement of the distal fragment
Flexion type Extension type
<5% >95%
SCH – Extension type
Mechanism of Injury
Fall on the outstretched hand
SCH – Extension type
Displacement of the distal fragment
Posteromedial Posterolateral
SCH – Extension type
Displacement of the distal fragment
Posteromedial Posterolateral
M L
SCH – Extension type
Clinical features
A child, H/O FOOSH
Pain, swelling, deformity and inability to move the limb
O/E
• Unusual prominence of the point of elbow
• Maintenance of 3 bony point relationship
Later stages, difficult to appreciate due to gross swelling
Neurovascular assessment
SCH – Extension type
Radiological diagnosis
2 standard views
Anteroposterior (AP) Lateral
SCH – Extension type
Principles of Radiological Assessment of the Elbow
Radio-capitellar line Anterior humeral line
SCH – Extension type
Principles of Radiological Assessment of the Elbow
Radio-capitellar line Anterior humeral line Sail sign
SCH – Extension type
Classification
SCH – Extension type
Treatment
SCH – Extension type
Reduction technique
SCH – Extension type
Post reduction: Immobilisation and Reassessment
Long arm posterior splint immobilisation Repeat Radiographs Repeat Neurovascular
with sling assessment
SCH – Extension type
Emergent Orthopedic referral
• Displaced/Angulation >20 degree
• Neurovascular compromise
• Open Injury
SCH – Extension type
Complications
Early
• Injury to Brachial artery (Volkmann’s Ischemia,
Compartment syndrome)
• Injury to nerves
• Median Nerve (M.C)
• Radial Nerve
SCH – Extension type
Complications
Late
• Malunion (Cubitus Varus – Gunstock
deformity)
SCH – Extension type
Complications
Late
• Malunion (Cubitus Varus – Gunstock
deformity)
• Myositis Ossificans
SCH – Extension type
Complications
Late
• Malunion (Cubitus Varus – Gunstock
deformity)
• Myositis Ossificans
• Volkmann’s ischemic contracture
Elbow Dislocation
Elbow Dislocation
Third most common in large joint
dislocations (Glenohumeral,
Patello-femoral)
Typically, young adult – sporting injury
Mechanism of Injury:
• Fall over outstretched hand
~90% cases: Posterior dislocations
Elbow Dislocation
50% cases: Associated bony
injuries
Radial head fracture
Coronoid process fracture
Elbow dislocation
“Terrible Triad”
Elbow Dislocation
Clinical features
H/O FOOSH
Pain, swelling, deformity and inability to move the limb
O/E
• Unusual prominence of the point of elbow
• 3 bony point relationship NOT maintained
Later stages, difficult to appreciate due to gross swelling
Neurovascular assessment
Elbow Dislocation
Radiological diagnosis
2 views:
• AP
• Lateral
Look for:
• Congruency: RC and UT Joints
• Radio-capitellar line
• Radial head fracture
• Coronoid process fracture
Elbow Dislocation
Reduction Methods
1) Traction and Flexion reduction method
Elbow Dislocation
Reduction Methods
2) Olecranon manipulation reduction method
Elbow Dislocation
Reduction Methods
3) Hanging arm reduction method
Elbow Dislocation
Reduction Methods
4) Single person reduction method
Elbow Dislocation
Post reduction: Immobilisation and Reassessment
Long arm posterior splint immobilisation Repeat Radiographs – Carefully look at the Repeat Neurovascular
with sling Radial head and Coronoid process assessment – Ulnar N.
Elbow Dislocation
Emergent Orthopedic referral
• Irreducible/Redisplacement
• Fracture dislocations (eg. Terrible Triad)
• Neurovascular compromise
• Open Injury
Proximal Humerus fracture
Typically elderly individuals with
osteoporotic bones
MOI: FOOSH, Fall on the shoulder
90% treated non-operatively
Cl/F
Pain, swelling, tenderness, inability to
move the limb
Bruising around the shoulder
Proximal Humerus fractures
Neer Classification
Displaced Fragment
4 Fragments
Displaced >1cm, or
Angulated >45 degree
Proximal Humerus fractures
No Fragment Displaced
~80%
1 Fragment Displaced
2 Fragments Displaced
3 Fragments Displaced
Proximal Humerus fractures
Radiological diagnosis
AP and Modified Axial view
Treatment
Immobilisation
• Collar and cuff supporting the wrist, or
• Sling and swathe
Orthopedic Referral
Open Fracture
Neurovascular compromise
Fracture dislocation of the humeral head
Proximal Humerus fractures
Complications
Axillary nerve injury
Axillary artery injury
Brachial Plexus injury
Ischemic necrosis of humeral head
Rotator cuff tear
Fracture shaft of Humerus
Bimodal age distribution
MOI
• Young - Direct blow
• Older – Simple fall on the arm, FOOSH
Most are treated non-operatively
Cl/F
Pain, swelling, tenderness, inability to
move the limb
Shortening of the limb may be present
Fracture shaft of Humerus
Radiological diagnosis
AP and Lateral view
• Characteristic displacement – Fracture
line in relation to Deltoid insertion
Holstein Lewis fracture
• Spiral fracture at the junction of middle
and distal third of humerus
• Higher chance of Radial nerve injury
(25%)
Fracture shaft of Humerus
Treatment
Immobilisation – 3 options
U-slab/Coaptation
splint
U-slab/Coaptation splint Hanging Cast Functional Bracing
(Acute immobilisation) (Not (After 2 weeks)
preferred)
Radial Head Fractures
Most common fracture around the
elbow
MOI: FOOSH
Cl/F
• Pain in lateral side of elbow
• Tenderness on palpating radial head
Radiological Diagnosis
• AP and Lateral Elbow views
Radial Head Fractures
Classification
Mason Classification
• Type 1: Minimally displaced
• Type 2: Simple fractures with some
displacement or angulation
• Type 3: Comminuted or displaced
• Type 4: Associated elbow dislocation
Radial Head Fractures
Most injuries: Isolated, minimally displaced and stable
Essex-Lopresti injury Terrible Triad injury
Radial Head Fractures
Treatment
Sling immobiliation
Orthopedic referral
Displaced/comminuted fracture
Essex-Lopresti Injury
Open fracture
Neurovascular compromise
Lateral and Medial Epicondylitis
Lateral and Medial Epicondylitis
Lateral Epicondylitis Medial Epicondylitis
(Tennis Elbow) (Golfer’s Elbow)
Extensor-Supinator origin Overuse syndrome Flexor-Pronator origin
Insidious onset pain Symptoms and signs Insidious onset pain
Worse: Wrist extension, Gripping Worse: Wrist flexion,
Point tenderness Gripping
Point tenderness
Clinical Diagnosis Clinical
Usually normal X-Rays Usually normal
Increased signal intensity at LE MRI Increased signal intensity at ME
Activity modification, Ice, Treatment Activity modification, Ice,
NSAIDs, Physiotherapy NSAIDs, Physiotherapy
Radial Nerve Nerve injury Ulnar Nerve
Biceps Tendon Rupture
2 Possibilities
• Long Head Rupture (Shoulder)
• Biceps Tendon avulsion (Elbow)
MOI
• Old age: Tendonopathy
• Young age: Excessive force (eg.
Bodybuilding)
X-Rays
• To rule out bony injury
Treatment
• Analgesia
• Immobilisation with collar and cuff
• Orthopedic referral
Biceps Tendon Rupture
Popeye Sign Biceps Squeeze Test Hook Test
