1. Dr. Bryon Hargrove CAPS FOM I Fall 2012
Elbow injuries
Dr. Bryon Hargrove
CAPS FOM I
Fall 2012

2. Objectives Revise a bit of pathoanatomy Learn elbow movements
Know common injuries
Know management of those injuries

3. Movements Extension (to 0 degrees) Flexion (145 degrees)
Gravity plus triceps
Flexion (145 degrees)
Biceps and brachialis
Pronation (75 degrees)
Pronator teres and pronator quadratus
Supination (80 degrees)
Biceps and supinator

5. Come Read My Tale Of Love
Figure Normal variation and development of the elbow in children. A, On an anteroposterior view of the left elbow, the medial epicondyle is visualized, but the lateral is not. B, On the right side, the lateral epicondyle is seen. This asymmetrical development from one side to the other can occur normally. Because lateral epicondyle fractures are rare, you should suspect that this is an apophysis.
Come Read My Tale Of Love
Capitellum, Radial head, Medial epicondyle, Trochlea, Olecranon, Lateral epidondyle
Age 1, 3, 5, 7, 9, 11
Mettler: Essentials of Radiology, 2nd ed., Copyright © 2005 Saunders, An Imprint of Elsevier

6. Disruption = displaced fracture
Know basic landmarks on lateral view to give clues to distinguish fracture from normal
Radiocapitellar line—points directly to capitellum
Anterior humeral line—middle 1/3 capitellum
Disruption = displaced fracture
Fat pad sign may be only clue if non-displaced

7.     FAT PAD SIGN

8. Fat Pad sign (aka. Sail Sign)
Anterior fat pad sign can be normal
Posterior always abnormal

9. Figure 9-3 Elevated fat pads anteriorly and posteriorly about the elbow indicate the presence of an elbow effusion. A, This lateral radiograph of the elbow in a child who sustained a nondisplaced supracondylar fracture shows a markedly displaced anterior fat pad. B, A lateral elbow radiograph of a different child shows no obvious fracture, but both an anterior and a posterior elevated fat pad can be noted. The child was treated for a supracondylar fracture that became evident 3 weeks later after observation of the periosteal reaction and fracture line.
Green: Skeletal Trauma in Children, 3rd ed., Copyright © 2003 Saunders, An Imprint of Elsevier

11. Most common injuries Supra-condylar fracture Radial head fracture
Olecranon fracture
Dislocation
Fracture dislocation
Pulled elbow

12. SUPRACONDYLAR FRACTURE Broadly divided in to:. Flexion type
SUPRACONDYLAR FRACTURE Broadly divided in to: .Flexion type .Extension type

24. Radiographic Evaluation
3 VIEWS ON AP-VIEW AND 3 VIEWS ON LATERAL VIEW. AP View: Baumann angle- 72 degrees ( should not be >81 degrees) Humeroulnar shaft angle- carrying angle Metaphyseal diaphyseal angle- 90 degrees LATERAL VIEW Anterior humeral line Anterior coronoid line Humerocondylar angle

33. Radial Head Subluxation
AKA “Nursemaids’ Elbow”
Common injury that is seen most often in children between the ages of 1-6 years
Occurs when longitudinal traction is placed on the hand while the elbow is extended and the forearm pronated.
Usually occurs when child falls and continues to be held by the hand, or when small children are swung by their arms.

34. Anatomy The annular ligament normally passes around the proximal
radius just below the radial
head. With traction on the
extended arm, the annular ligament slides over the head of the radius into the joint space and becomes entrapped
Common early childhood injury because at an early age, the radial head is spherical and is composed mainly of cartilage

35. Clinical Presentation
history of arm being pulled
injured elbow pronated, partially flexed and held by side, child will not use
there is anterolateral tenderness over the radial head
no swelling, redness, warmth, abrasions, or ecchymosis
have been reports of infants < 6 months old with a history of not using arm after rolling over and their arms getting caught

36. Radiographs
Diagnosis is by history and physical examination. Radiograph examination is usually not necessary and are normal in most instances.
If x-rays are taken, often the subluxation is reduced when the technician positions the arm on the plate.
Radiographs become necessary if pain continues post-reduction.

37. Reduction Cup affected elbow with opposite hand
Apply pressure over radial head
Thumb in antecubital fossa
Apply slight longitudinal traction by grasping wrist
Supinate (palm up) and flex (to 90 degrees) forearm
Palpable click felt with reduction

38. Post-reduction Management
Child should be pain-free and use arm within
0-15 minutes. Immobilization optional (Sling for 1-2 days)
If child fails to use arm after 15 minutes, obtain elbow views to rule out concomitant fracture
If x-rays normal but child still not using arm, use a posterior splint and sling and re-evaluate in 24 hours
If child has 3 recurrent episodes of subluxation, then apply hard cast for 3 weeks

39. Elbow X-ray Views: Technique: Evaluation: AP Oblique Lateral
Elbow in 90 degree flexion
Compare with opposite elbow
Evaluation:
The radial head should always point at the capitellum in all views. A line drawn down the long axis of the radius (radial head) should intersect the capitellum in all views (if the line doesn’t intersect, this is a sign of dislocation)

40. Fracture over olecranon
Mechanism
-fall on point of elbow
-sudden triceps contraction
Don’t forget epiphyses

41. Olecranon fractures
Hairline and undisplaced fractures can be treated in long arm cast for 3-4 weeks in children and 6-8 weeks in adults
If fragment large/displaced will require fixation e.g. tension band wiring

42. Isolated Radial Head Dislocation
Very rare
Can occur in children because bones are more plastic.
Usually anterior, very rarely posterior and lateral.
ULNAR BOW SIGN by Lincolin and Mubarak.

43. If more than 1mm show dislocated radial head.
Usually <1mm
If more than 1mm show dislocated radial head.
Also called ‘Minimal Monteggia Fracture’.
Close Reduction if <3 week old.
(Forearm supination + 90 flexion – anterior dislocation, Forearm pronation + 90 elbow flexion- Posterior dislocation)
ORIF if > 3 weeks old.

44. Radial Head and Neck Fracture
Occur at 4-14 years of age.
Most fractures in children are of radial neck.
Numerous classifications like Rostal, Newman, O’Brian and Jeffery.
Wilkin combined classification of Newman and Jeffery.
A-    SH I or II
B-    SH IV
C-    Metaphysical fracture
D-    Fracture occurring when dislocated elbow is reduced.
E-     Fracture occurring with elbow dislocation.

45. After dislocation the fragment can lie loose in the joint or it can be trapped which prevents reduction.
Between angulations is acceptable. Whenever angulations is >45, elbow is maneuvered to reduce it to below 45.

46. Patterson technique Pesudo technique Metaizeau technique
     Patterson technique
      Pesudo technique
      Metaizeau technique
      ORIF via Boyd approach.

47. Complications: Loss of motion. Pre-mature physeal closure.
No radial neck.
AVN radial head.
RIU synostosis.
Myositis Ossificans.
Injury to posterior interosseous nerve.

48. Lateral Condyl Fracture
More common than medial epicondyl and condyl
Quite common.
Classified by:
Ø      Milch
Ø      Roentgenographic
Ø      Amount of displacement.

49.           MILCH CLASSIFICATION
1- TYPE I (Salter n Harris-IV) 2- TYPE-II (Salter n Harris-ii)

50. Roentgenographic Classification
Minimal Lateral Gap
Average Lateral gap
Fracture gap as wide Laterally as medially
   
Amount of Displacement
                       (Kay Wupon's classification)
Undisplaced ( 2mm or less dis at metaphyses)
Moderately Displaced (2-4mm)
Completely displaced (>4mm) and rotated.

51. TREATMENT SPEED AND BOYD ORIF for displaced fractures
                                   
                                   SPEED AND BOYD
ORIF for displaced fractures
CR with immobilization for undisplaced fractures but close observation every 5-7 days is necessary.

52. BEATY AND WOOD USED VARUS AND VALGUS STRESS TEST TO FIND
OUT IF FRACTURE IS STABLE AND RECOMMENDED
ORIF IF IT DISPLACES WITH STRESS.

53. MINTZER Recommended CR and PCP for fractures
with  minimal   displacement (<2cms) and
congruent joint surfaces.

54. ORIF DONE VIA LATERAL APPROACH.
AIM IS TO REPLACE FRAGMENT WITH MINIMAL DISSECTION AND FIXATION WITH;
            
        1- Suture which is inadequate and is not recommended.
        2- Smoot pins either through epiphyses or metaphysea
            spike.
        3- Screw fixation - probably through metaphyseal area.
            However Conner and Smith used a Glassgow screw
           through the physis and epiphyses and didnt notice any 
           growth disturbance.   

62. THANK YOU