Injuries of upper arm and elbow pdf - د. عمار طالب الياسري

Baghdad College of Medicine / 5

grade

Student’s Name :

Dr. Ammar Talib Al-
Yasseri
Lec. 2

Injuries of upper arm &
elbow

Wed. 19 / 10 / 2016

DONE BY : Mustafa Naser

مكتب اشور لالستنساخ

2016 – 2017

Injuries of upper arm Dr. Ammar

19-10-2016

©Ali Kareem 2016-2017

Injuries of upper arm and elbow

FRACTURES OF THE PROXIMAL HUMERUS

o  occur after middle age
o  most of the patients are osteoporotic, postmenopausal women
o  Mechanism of injury: fall on the out-stretched arm
o  Classification and pathological anatomy

  Neer
  four major segments
  distinguishes between the number of displaced fragments, with

displacement defined as greater than 45 degrees of angulation or 1 cm
of separation.

Clinical features:

o pain may not be severe.
o large bruise on the upper

part of the arm is suspicious.

o Signs of axillary nerve or

brachial plexus injury should
be sought.

Injuries of upper arm Dr. Ammar

19-10-2016

©Ali Kareem 2016-2017

X-ray:

o  In elderly
o  In younger patients,
o  Axillary and scapular-lateral views should always be obtained, to exclude

dislocation of the shoulder.

o The advent of three-dimensional CT reconstruction

Treatment

o MINIMALLY DISPLACED FRACTURES

 a week or two period of rest with the arm in a sling until the pain

subsides,

 gentle passive movements of the shoulder.
 Once the fracture has united(usually after 6 weeks) active exercises

o TWO-PART FRACTURES

  Surgical neck fractures
  Greater tuberosity fractures
  Anatomical neck fractures

o  THREE-PART FRACTURES
o  FOUR-PART FRACTURES
o  FRACTURE-DISLOCATION

Complications

o  Vascular injuries and nerve injuries:
o  Avascular necrosis:
o  Stiffness of the shoulder:
o  Malunion:

FRACTURES OF THE PROXIMAL HUMERUS IN CHILDREN

o At birth, the shoulder is sometimes dislocated or the proximal humerus

fractured. Diagnosis is difficult and a clavicular fracture or brachial plexus
injury should also be considered.

Injuries of upper arm Dr. Ammar

19-10-2016

©Ali Kareem 2016-2017

o In infancy, the physis can separate (Salter–Harris I); reduction does not have

to be perfect and a good outcome is usual.

o In older children,

 metaphyseal fractures or Type II physeal fractures occur.
 Pathological fractures are not unusual,

FRACTURED SHAFT OF HUMERUS

Mechanism of injury:

o A fall on the hand may twist the humerus, causing a spiral fracture.
o A fall on the elbow with the arm abducted exerts a bending force, resulting

in an oblique or transverse fracture.

o A direct blow to the arm causes a fracture which is either transverse or

comminuted.

o Fracture of the shaft in an elderly patient may be due to a metastasis.

Pathological anatomy:

o  With fractures above the deltoid insertion
o  With fractures lower down,
o  Injury to the radial nerve is

common, though fortunately
recovery is usual.

Clinical features:

o  painful,
o  bruised
o  swollen.
o  test for radial nerve function before and after treatment.

X-ray: The site of the fracture, its line (transverse, spiral or comminuted) and any
displacement are readily seen. The possibility that the fracture may be pathological
should be remembered.

Injuries of upper arm Dr. Ammar

19-10-2016

©Ali Kareem 2016-2017

Treatment:

‘hanging cast’ replaced after 2–3 weeks by

o a short (shoulder to elbow) cast or a functional polypropylene brace (6

weeks).

o  The wrist and fingers are exercised from the start.
o  Pendulum exercises of the shoulder are begun within a week
o  active abduction is postponed until the fracture has united (about 6 weeks for

spiral fractures but often twice as long for other types)

OPERATIVE TREATMENT

Indications for surgery :

o  severe multiple injuries
o  an open fracture
o  segmental fractures
o  displaced intra-articular extension of the fracture
o  a pathological fracture
o

a ‘floating elbow’ (simultaneous unstable humeral and forearm fractures)

o  radial nerve palsy after manipulation
o  non-union
o  problems with nursing care in a dependent person.

Complications

EARLY :

o Vascular injury:
o Nerve injury:

LATE :

o Delayed union and non-union:

Injuries of upper arm Dr. Ammar

19-10-2016

©Ali Kareem 2016-2017

 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.

o Joint stiffness: Joint stiffness is common. It can be minimized by early

activity,

FRACTURES OF THE DISTAL HUMERUS IN ADULTS

o High-energy injuries which are associated with vascular and nerve damage.
o The AO ASIF Group have defined three types of distal humeral fracture:

 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.

Injuries of upper arm Dr. Ammar

19-10-2016

©Ali Kareem 2016-2017

 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
 Displaced Type B and C fractures

 Complications

EARLY:

 Vascular injury
 Nerve injury:

LATE

 Stiffness:
 Heterotopic ossification

FRACTURED CAPITULUM

o  a rare articular fracture
o  occurs only in adults.
o  The patient falls on the hand, usually with the elbow straight. The anterior

part of the capitulum is sheared off and displaced proximally.

o Clinical features :

  Fullness in front of the elbow
  The lateral side of the elbow is tender
  flexion is grossly restricted.

o 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.

o Treatment :

 Undisplaced fractures can be treated by simple splintage for 2 weeks.
 Displaced fractures should be reduced and held. Operative treatment

is therefore preferred.

Injuries of upper arm Dr. Ammar

19-10-2016

©Ali Kareem 2016-2017

FRACTURED HEAD OF RADIUS

o common in adults but are hardly ever seen in children
o Mechanism of injury: A fall on the outstretched hand with the elbow

extended and the forearm pronated

o Clinical features : tenderness on pressure over the radial head and pain on

pronation and supination should suggest the diagnosis.

o 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.

o Treatment :

FRACTURES OF THE OLECRANON

o Two broad types of injury are seen:
o (1) a comminuted fracture which is due to a direct blow or a fall on the

elbow; and

o (2) a transverse break, due to traction when the patient falls onto the hand

while the triceps muscle is contracted.

o  further sub-classified into (a) displaced and (b) undisplaced fractures.
o  Clinical features:
o  X-ray
o  Treatment

  comminuted fracture
  An undisplaced transverse fracture
  displaced transverse
  Displaced comminuted fractures

Injuries of upper arm Dr. Ammar

19-10-2016

©Ali Kareem 2016-2017

Dislocation of the elbow

o  most common joint dislocation second to the shoulder
o  more in adults than in children
o  classified according to the direction of displacement.
o  in 90% of cases the radioulnar complex is displaced posteriorly or

posterolaterally

o Often together with fractures of the restraining bony processes

Mechanism of injury and pathology

o fall on the outstretched hand with the elbow in extension.
o If there is no associated fracture, reduction will usually be stable and

recurrent dislocation unlikely.

o The combination of ligamentous disruption and fracture of the radial head,

coronoid process or olecranon process (or, worse still, several fractures) will
render the joint more unstable

o surrounding nerves and vessels may be damaged.
o 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

o  The patient supports his forearm with the elbow in slight flexion.
o  Unless swelling is severe, the deformity is obvious.
o  The bony landmarks (olecranon and epicondyles) may be palpable and

abnormally placed.

o the hand should be examined for signs of vascular or nerve damage
o X-ray :

 confirm the presence of a dislocation
 identify any associated fractures

Treatment :

Injuries of upper arm Dr. Ammar

19-10-2016

©Ali Kareem 2016-2017

o 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 put through full range of

movement to see whether it is stable

o  The distal nerves and circulation are checkcd again.
o  an x-ray is obtained
o  The arm is held in a collar and cuff with the elbow flexed above 90 degrees.
o  After 1 week the patient gently exercises his elbow; at 3 weeks the collar

and cuff is discarded

o 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

o 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)

o Olecranon process

 Open reduction with internal fixation is the best treatment.

Complications

EARLY

Injuries of upper arm Dr. Ammar

19-10-2016

©Ali Kareem 2016-2017

o 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.

o Nerve injury

 The median or ulnar nerve is sometimes injured. Spontaneous

recovery usually occurs after 6-8 weeks.

LATE

o 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

o 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

o 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

o Recurrent dislocation

Injuries of upper arm Dr. Ammar

19-10-2016

©Ali Kareem 2016-2017

 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.

o Osteoarthritis

 Quite common after severe fracture dislocations
 In older patients, total elbow replacement can be considered

Fractures around the elbow in children

SUPRACGNDYLAR FRACTURES

o  Among the commonest fractures in children.
o  The distal fragment may be displaced either posteriorly or anteriorly
o  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

o 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.

Injuries of upper arm Dr. Ammar

19-10-2016

 Type III is a completely displaced fracture

Clinical features

o  pain
o  elbow is swollen;
o  with a posteriorly displaced fracture the S-deformity of the elbow is usually

obvious

o  It is essential to feel the pulse and check the capillary return;
o  passive extension of the flexor muscles should be pain-free.
o  The wrist and the hand should be examined for evidence of nerve injury.

X-ray

o The fracture is seen most clearly in the lateral view.
o

In an undisplaced fracture the ‘fat pad sign’ should raise suspicions

o 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.

o In the anteriorly displaced fracture the crack runs downwards and backwards

and the distal fragment is tilted forwards.

o An AP View is often difficult to obtain without causing pain
o It may show that the distal Fragment is shifted or tilted sideways and rotated

usually medially

Treatment

o TYPE I UNDISPLACED FRACTURE

Injuries of upper arm Dr. Ammar

19-10-2016

 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

o 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.

o 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.

o 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

Injuries of upper arm Dr. Ammar

19-10-2016

o 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

o 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.

o 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

o 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

Injuries of upper arm Dr. Ammar

19-10-2016

 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

#END of this Lecture…