The Disorder of Elbow

Ligaments of the
elbow

Elbow Dislocation

Classification of adult elbow dislocations .

• According to the direction of displacement of the ulna relative to the humerus – Posterior – Posterolateral – Posteromedial – Lateral – Medial – Anterior • The most common elbow dislocation is a posterior dislocation. which accounts for 90% of cases .

Posterior Dislocation • Posterior dislocations is condition in which the olecranon is displaced posteriorly in relation to the distal humerus • The mechanism of injury is a fall on the extended and abducted arm .

Physical Examination • The limb held in flexion at 45° • The olecranon is prominent posteriorly • Moderate swelling and deformity at the joint .

radial head. Imaging • Standard anteroposterior and lateral radiographs of the elbow should be obtained • Reveal an empty olecranon fossa posterior to the distal humerus • Associated fractures include the coronoid process. and occasionally the humeral epicondyles or capitellum .

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and function should be checked before and after reduction • Injury to the brachial artery is rare with posterior dislocations of the elbow • Median nerve entrapment may also occur in patients with posterior dislocations • The wrist and shoulder must be examined thoroughly . Associated Injuries • Commonly associated injuries are to the peripheral nerves. especially the ulnar nerve.

surgical repair is rarely needed because the flexor and extensor musculature acts as a strong secondary stabilizer that resists redislocation .• All elbow dislocations that are not associated with concomitant elbow fractures will demonstrate rupture of the medial and lateral ligaments • Although these ligaments are the primary stabilizers of the elbow.

Treatment • Early reduction is advocated. as delay may damage the articular cartilage or result in excessive swelling or circulatory compromise • The reduction technique is a modification of the Stimson technique used in shoulder reductions • One must be careful to avoid forceful manipulation during reduction. as this can result in myositis ossificans .

The patient lies prone on a stretcher. the physician lifts up gently on the arm.(A) Parvin’s method of closed reduction of an elbow dislocation. As the olecranon begins to slip distally. and if the maneuver is done gently. no anesthesia is required . No assistant is required. and the physician applies gentle downward traction of the wrist for a few minutes.

As gentle downward traction is applied on the wrist.(B) In Meyn and Quigley’s method of reduction. the physician guides reduction of the olecranon with the opposite hand . only the forearm hangs from the side of the stretcher.

reduction usually occurs within a period of 5 to 10 minutes. With proper muscle relaxation.In this technique weights are suspended from the wrist while the arm is held over the edge of the bed as shown. If using a bucket. A folded sheet can be placed under the arm to allow free movement of the forearm as the reduction occurs. weights can be added as needed .

To perform this reduction. With one hand. This method involves gentle disengagement of the coronoid process without excessive traction and hyperextension that can lead to soft-tissue damage when the olecranon impinges on the lower humerus. the patient's forearm is grasped.A second technique that can be performed in the supine patient. With the other hand. the elbow is grasped such that the thumb is placed over the displaced olecranon Gentle traction is applied while the patient's elbow is gradually flexed to disengage the coronoid process from the lower humerus . the emergency physician stands on the contralateral side of the patient's injured elbow.

• After reduction of the elbow. the ligaments are stress tested and the elbow is immobilized at 90° in a long-arm posterior splint • The length of immobilization is approximately 5 to 10 days • Following manipulation or reduction. repeat neurovascular examination should be performed to assess neurovascular status • Postreduction radiographs are essential .

• Radial head fractures and large coronoid fractures will usually require operative repair following closed reduction . • Small coronoid fractures do not require further management.Surgery is indicated in cases where • Closed reduction is unsuccessful • When redislocation occurs with 50° to 60° of flexion • When unstable fractures are present around the joint.

4. Post-traumatic joint stiffness. Lateral elbow instability. 3. . Neurovascular injuries. 2. Complications 1. Heterotopic ossification (HO).

making this dislocation potentially more problematic . Anterior Dislocations • Anterior dislocations are far less common. occurring from a blow to the flexed elbow that drives the olecranon forward • Associated injuries to vessels and nerves around the joint are much more common with anterior dislocations.

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• The elbow is usually held in full extension. • The olecranon fossa is often palpable anteriorly • Many of these dislocations are open. and vascular damage is quite common . the arm appears shortened and the forearm is elongated and held in supination. Physical Examination • On examination.

Ulnar Collateral Ligament Injuries • MOI = valgus force from repetitive trauma • Secondary injuries may include… – Ulnar nerve inflammation – Wrist flexor tendonitis – Joint instability .

UCL Injuries • Signs and Symptoms – Pain along medial aspect of elbow – Point tenderness over UCL – Associated paresthesia (Reason:?) .

UCL Injuries • Management – Conservative treatment • NSAID’s – ROM and PRE exercises as pain decreases – Analysis of the throwing motion (if applicable) – Surgical intervention may be necessary .

muscle spasm . swelling. Elbow Injuries: Fractures • MOI = fall on flexed elbow or direct blow – May occur in one or more of bones in elbow joint • Signs and Symptoms – May not result in visual deformity – Hemorrhaging.

•Type B Unicondylar fractures : B1 fracture of the lateral condyle B2 fracture of the medial condyle B3 tangential fracture of the condyle •Type C Bicondylar fractures : C1 T or Y-shaped fractures C2 T or Y-shaped fractures with comminution C3 extensive comminution of the condyles . Distal Humerus Fracture A-O Classification of distal humeral fractures •Type A Extraarticular fractures : A1 epicondylar avulsions A2 supracondylar fractures A3 supracondylar fractures with comm.

Management Supracondylar fractures – Extension type • Minimally displaced: Immobilization in posterior spllint 1-2 weeks. prefared double plating – Flexion type • Closed reduction • ORIF. immobilzation in posterior splint 4 – 6 weeks – Olecranon traction – ORIF. that canot be held closed methode . early mobilization • Displaced fracture – Closed reduction.

gravitaion. skletal) • Operative method : – Pin in plaster – ORIF plate and screw . divided into: – Casting immobillization – Traction ( skin. Management Transcondylar • Closed reductin (especially minimally fractured displaced) following • Casting immobillization or percutaneus pinning Intercondylar T or Y fractures • Closed reduction for type I.

Comminuted fracture of supracondylar intraarticular of humerus with double plate fixation .

B: Type II injury with marginal fracture and displacement. Radial Head Fracture Mason's classification of radial head fractures. . nondisplaced. C: Type III radial head fracture demonstrating comminution of the entire head. D: Type IV injury a radial head fracture in association with an elbow dislocation. A: Type I radial head fracture.

Radial Head Fractures • Management : – Type I : minimal immobilization and early motion – Type II : ORIF and early motion – Type III : ORIF and early motion if possible – Type IV : radial head resection and fixation of distal radioulnar joint .

Fractures Of Epicondyles • Fractures of lateral epicondyle • Fractures of medial epicondyle .

Olecranon Fracture Colton classification of olecranon fractures A: Type I. D: Type IV. severe comminution of the olecranon. . B: Type II. C: Type III. avulsion of the olecranon process. fracture from the deepest portion of the semilunar notch. fracture at the most distal portion of the olecranon.

Management • Nondisplaced Fractures – Immobilization 3 – 4 weeks in casting above elbow with elbow fleksion 40 – 90 degree – Union in 6-8 weeks • Displaced fractures ORIF treatment of choice for displaced # .

Excision . Intramedullary fixation 2. AO Plate 5.Operation method: 1. Bicortical screw fixation 4. Tension Band Wiring (TBW) 3.

– Type III is a fracture of the entire coronoid process. . Coronoid process fractures • Regan and Morrey as follows : – Type I is a small chip fracture that has no clinical importance but suggests the possibility of an elbow dislocation. – Type II involves 50% of the coronoid process and may or may not be associated with an unstable elbow.

Management • Type I : No treatment other than symptomatic • Type II : If the ulnar humeral joint is unstable. and unfixable. . • Early motion in all of these fractures is important. fixation is indicated or external fixator • Type III : ORIF indicated if the fracture not too comminuted.