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
 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, radial head, and occasionally the
humeral epicondyles or capitellum
 Associated Injuries
Commonly associated injuries are to the peripheral
nerves, especially the ulnar nerve, 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
 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, surgical repair is
rarely needed because the flexor and
extensor musculature acts as a strong
secondary stabilizer that resists redislocation
 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
(A) Parvins method of closed reduction of an
elbow dislocation.

The patient lies prone on a stretcher, and the

physician applies gentle downward traction of
the wrist for a few minutes.

As the olecranon begins to slip distally, the

physician lifts up gently on the arm.

No assistant is required, and if the maneuver is

done gently, no anesthesia is required
(B) In Meyn and Quigleys method of
reduction,

only the forearm hangs from the side of the

stretcher.

As gentle downward traction is applied on the

wrist, the physician guides reduction of the
olecranon with the opposite hand
In this technique weights are suspended from
the wrist while the arm is held over the edge of
the bed as shown.

A folded sheet can be placed under the arm to

allow free movement of the forearm as the
reduction occurs.

With proper muscle relaxation, reduction

usually occurs within a period of 5 to 10
minutes.

If using a bucket, weights can be added as

needed
A second technique that can be performed in
the supine patient.

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.

To perform this reduction, the emergency

physician stands on the contralateral side of the
patient's injured elbow.

With one hand, the patient's forearm is grasped.

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
 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
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.
Small coronoid fractures do not require further
management.
Radial head fractures and large coronoid fractures
will usually require operative repair following
closed reduction
 Complications
1. Neurovascular injuries.
2. Post-traumatic joint stiffness.
3. Heterotopic ossification (HO).
4. Lateral elbow instability.
 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, making this dislocation
potentially more problematic
 Physical Examination
On examination, the arm appears shortened and
the forearm is elongated and held in supination.
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
 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
NSAIDs
ROM and PRE exercises as pain decreases
Analysis of the throwing motion (if applicable)
Surgical intervention may be necessary
 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, swelling, muscle spasm
 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.
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
 Management
Supracondylar fractures
Extension type
Minimally displaced: Immobilization in posterior
spllint 1-2 weeks, early mobilization
Displaced fracture
Closed reduction, immobilzation in posterior splint 4 6
weeks
Olecranon traction
ORIF, prefared double plating
Flexion type
Closed reduction
ORIF, that canot be held closed methode
 Management
Transcondylar

Closed reductin (especially minimally fractured displaced) following

Casting immobillization or percutaneus pinning

Intercondylar T or Y fractures

Closed reduction for type I, divided into:

Casting immobillization
Traction ( skin, gravitaion, skletal)

Operative method :

Pin in plaster
ORIF plate and screw
Comminuted fracture of supracondylar intraarticular of
humerus with double plate fixation
 Radial Head Fracture

Mason's classification of radial head fractures.

A: Type I radial head fracture, nondisplaced.

B: Type II injury with marginal fracture and

displacement.

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.
 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, avulsion of the olecranon

process.

B: Type II, fracture from the deepest

portion of the semilunar notch.

C: Type III, fracture at the most distal

portion of the olecranon.

D: Type IV, severe comminution 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 #
Operation method:
1. Intramedullary fixation
2. Tension Band Wiring (TBW)
3. Bicortical screw fixation
4. AO Plate
5. Excision
 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.
Type III is a fracture of the
entire coronoid process.
 Management

Type I : No treatment other than

symptomatic
Type II : If the ulnar humeral joint is
unstable, fixation is indicated or external
fixator
Type III : ORIF indicated if the fracture not too
comminuted, and unfixable.
Early motion in all of these fractures is important.