The elbow joint is a synovial joint of hinge variety.

The elbow joint is formed between the lower end of the humerus and the upper ends of the radius and the ulna.

It is analogous to the knee joint in the lower limb.

 Anteriorly:

Brachialis, median nerve, brachial artery, tendon of biceps.

Triceps, anconeus.

Posteriorly: Medially:

Ulnar nerve, flexor carpi ulnaris, common flexors. Supinator, extensor carpi radialisbrevis, other common extensors.

Laterally:

Carrying Angle:

A supracondylar fracture is a fracture of the distal humerus just above the epicondyles. While relatively rare in adults it is one of the most common fractures to occur in children and is often associated with the development of serious complications.

Supracondylar

fracture is broadly classified into two types:

type: The fracture line runs downwards and forwards. type: The fracture line runs upwards and backwards.

FLEXION

EXTENSION

GARTLANDS CLASSIFICATION Type I- un-displaced. Type II- displaced but posterior cortex is intact. Type III- displaced but no intact posterior cortex and the distal fragment could be either displaced: Posteromedial Postero-lateral

X-ray showing partially displaced and completely displaced supracondylar fracture:

 Fall

on outstretched hand with hyperextension at the elbow with abduction or adduction, with hand dorsi-flexed.

The following are the characteristic clinical signs in supracondylar fracture: Arm is short, forearm is normal in length. Gross swelling, and tenderness. Crepitus is present S shaped deformity. Relationship between the three bony points is maintained. Movements of the elbow both active and passive are decreased.

 Conservative

Surgical

treatment:
Initially

treatment:
It

closed reduction is tried under general anesthesia by traction and counter traction methods.

is indicated if conservative methods fail;

Supracondylar fracture can be treated based on the classification: Type 1 fractures are treated with simple immobilization in a plaster cast without any manipulation. Type 2 fractures are treated by manipulation followed by immobilization in a plaster cast. The cast is kept for three weeks. Type 3 fractures require operative treatment. An attempt is made to reduce the fracture without exposing the bone fragments through an incision. If successful then the fracture is held in place by 1.5 or 2mm stainless steel wires called K wires.

If this is unsuccessful then the fracture is exposed by a incision and the bone fragments are aligned under vision. They are then held in place by K wires.

A pre-operative and post-operative x ray photo of a type 3 fracture. You can see the K-wires in the postoperative x ray photo.

Those that cause functional impairment of the extremity and is more serious: Neurological Involvement: Overall incidence is around 7%. Vascular Injury Volkmanns Ischaemia Loss of mobility Myositis ossificans

Those that produce only a cosmetic sequelae. Cubitus varus is called so because the deformity resembles a rifle gunstock. This is the most common complication of the supracondylar fracture. Incidence varies from 9 to 58%. The deformity becomes obvious in an extended elbow.

Orthopedic goals Rehabilitation Goals Muscle strengthening exercises are carried out for triceps, biceps, forearm supinator and pronators, wrist flexors and extensors and deltoid muscles. Functional goals

Conservatively managed patients (cast/splint): Here the stability of the fracture is poor. The cast is trimmed to the distal palmar crease so as to allow the fingers to move freely.

Children treated with percutaneous pinning: Here only pin afford stability to the fracture site. The cast ends at the distal palmar crease to allow free finger movements.

Children treated with open reduction and internal fixation: Fractures treated by this method are quite stable and the arm is supported either by sling, slab or a functional brace. Gentle active ranges of movements are begun to the entire extremity, involving the shoulder, elbow, wrist, forearm and fingers.

Conservative Management: Active range of motions exercises to the digits; active and active assistive exercises to the shoulder are begun. Grip strengthening exercises are commenced with ball or putty. Percutaneous pinning: The regime is more or less similar to the one prescribed above. Open reduction and internal fixation: The gentle active range of movements exercises for the active extremity including shoulder, elbow, forearm, wrist or fingers are continued. Grip strengthening exercises are begun.

Conservative Management: at this stage, clinical stability and radiographic evidence of healing are assessed. If present, a supervised, rhythmic active elbow range of movements are commenced by using roller skates on a dining table. Percutaneous pinning: Remove the pins and protect the arm with a posterior splint or brace. Rest of the regime is same as mentioned above. Open reduction and internal fixation: functional cast brace or splint is discarded. Active and activeassisted exercises to the entire extremity and grip strengthening exercises are continued. Passive ranges of movements to the elbows are avoided.

Conservative Movements: Braces, splints, slings are discontinued. Continue active and add passive range of motion exercises to all the joints of the extremity. Beginning with 1-2 pounds weight in gradation, resistive exercises are commenced
Percutaneous pinning, Open reduction and internal fixation : The regime is same.

Accounts for 16.8% fractures of distal humerus and can be associated with the dislocation of the elbow and fracture of the olecranon.

 Anatomical

Location: Type I- fracture line lateral to trochlea through the capitulo-trochlear groove. Elbow is stable. (high Jupiter fracture) Type II- fracture line extends into apex of the trochlea, elbow is unstable. (low Jupiter fracture)

 Stages

of Displacement: Un-displaced Displaced Displaced and rotated

Stage I and II: Closed reduction and percutaneous pinning.

Stage III or if the fracture is > 24-48 hours old: Open reduction and K-wire fixation.

 Lateral

Condylar outgrowth. Delayed union and non-union Cubitus Valgus- common complication. Cubitus Varus Acute injury to the posterior interosseous nerve may be seen. Tardy Ulnar nerve palsy Physeal growth arrest. Avascular necrosis. Myositis ossificans

 It

is rare in children about 1%and affects the children in the age group of 8- 14 years.

 Based
Type

on Anatomical Location (Milch):

I- fracture line through the apex of the trochlea. Type II- fracture line through the capitulotrochlear groove.

 Stages

of Displacement (Kilfoyles):

Impacted Complete

Displaced

and rotated

Presenting Complaints: Following a fall with outstretched arm and Valgus strains the child and complains of pain on the medial side of the elbow. The elbow appears deformed. On examination: On examination, child resists attempts at movement of the elbow but if dislocated, movement of the joint is completely blocked. The relationship of making an isosceles triangle is altered. There is diffuse swelling on around the elbow.

 Stage

I and II: Above elbow cast or splint.

Stage

III: Open reduction and internal fixation.

 Missed

Diagnosis Nonunion with cubitus varus Delayed Union Cubitus Valgus due to growth stimulation Ulnar Neuropathy

 This

is a T or Y fracture of the inter-condylar fracture of the Humerus seen commonly in adults.

Intercondylar fracture in adults. Fracture (A); reduction by pressure over the fragments while traction is applied (B).

 Direct

trauma due to fall on a pointed elbow, with the olecranon being driven between the condyles of the Humerus. More often than not these fractures are comminuted.

 Patients

complain of extreme pain, swelling, loss of mobility at the elbow joint, crepitus, abnormal mobility, etc. There may be features suggestive of injuries to the blood vessels and nerves.

Surgery is the treatment of choice and consists of open reduction and internal fixation with either screw only or by plate and screws. Overhead olecranon skeletal traction is the other method of treatment but is associated with recumbent problems.
Conservative treatment has little or no role in this type of fractures.

This is more or less similar to the Supracondylar fractures. The additional measures are:
Thermotherapy: This is used more extensively Mobilization of elbow by roller skates is done more gently and for a prolonged period of time

Collar and cuff stretching effect and maintenance of the corrected flexion obtained. Passive stretching exercises after 6 months to regain further movements of the elbows.

 It

is rare in children below 10 years of age. Fifty percent of all dislocations occur in patients less than 20 years of age.

Incidence-

3 to 6 percent Males- 71 percent Non dominant extremity- 62 percent.

 This

is frequently due to fall on outstretched hands with elbow slightly flexed.

vagus twist is added to the longitudinal force by the projecting trochlea and thus the dislocation is posterior lateral.

Commonly

seen in sporting events and in

RTA.

According to Stimson, elbow dislocation can be described with respect to the position of the radio-ulnar unit to the distal humerus.
Proximal Radio-ulnar Joint Intact Proximal Radio-ulnar Joint Disrupted ( Divergent Dislocation) A. Antero-posterior A. Posterior (90%)

B.

Postero-lateral Posteromedial Anterior

B.

Radius is anterior Ulna is posterior Medio-Lateral ( transverse)

C.

Medial

Radius is lateral Ulna is medial

D.

Lateral

Presenting Complaint: Patient experiences considerable pain and supports the arm to the side of the body with his normal arm. The patients with unreduced posterior dislocation of the elbow joint have fixed flexion deformity and gross restriction of the elbow movements. On examination: The normal relationship between the tip of the Olecranon and the two epicondyles in flexed position of the elbow may be same or the tip of tip of olecranon may move up tha level.

During the first 3 Weeks : This is the period when the elbow is immobilized in a plaster cast/ splint after reduction. The steps to be followed during this critical period is enumerated as under: Check Exercises To maintain an elevated position, the arm is kept on the table and the figures and thumb are exercised vigorously. Teach

The generous task of putting the injured and immobilized elbow back to its pre-injured state, test the dexterity and acumen of any physiotherapy. A systematic logical approach is briefed below could help solve the problem: Pre-mobilization phase Mobilization phase Note: Roller states are more effective if used on a powdered sun mica board. Forearm supination/ pronation

 Avulsion

fracture of medial epicondylar epiphysis.

proximal radius and coronoid process of ulna Olecranon, trochlea, and lateral Condylar physis.

Fracture

Fracture

Neurological Injuries Myositis ossificans Arterial Injuries Proximal Radio-ulnar Translation Recurrent Dislocation Osteo-chondral Fractures Unreduced dislocation Ectopic Calcification

Fracture Olecranon is uncommon in children. Olecranon fracture in adults is comparable to the fracture of patella. The fracture fixation should be strong enough to allow gentle active exercises even before radiographs show evidence of complete union.
As separation of the fracture of patella causes quadriceps insufficiency so does displaced fracture olecranon causes triceps insufficiency.

 Direct

Trauma due to fall on the point of elbow. This is the frequent cause.
due to forcible triceps contraction.

Indirect

 Un-displaced

fracture Displaced fracture Avulsion fracture Transverse / oblique fracture Fracture dislocation (Monteggia group) Comminuted fracture

 The

patient complains of pain, swelling and inability to extend the elbow, Clinically, tenderness and crepitus can be elicited.

 Nonunion

of the fracture
of the elbow

Osteoarthritis Triceps

insufficiency movements of the elbow

Restricted

Conservative Management: During the first week: No movements are permitted at the elbow. No strengthening exercises to the elbow. Isometric exercises to the wrist within the cast after 3-4 days. Unaffected extremity is used for daily care.

No weight bearing is permitted.

 Isometric

exercises to the elbow are permitted. Rest same as above.

 Active

range of motion to the elbow is started. Isometric exercises to the elbow and wrist. The patient can use affected extremity for daily care activities. No weight bearing is permitted.

 Full

active range of movements to the elbow and wrist in all planes. Resistive exercises to the elbow and wrist. The involved extremity can be used for daily care activities. Gradual weight bearing is permitted. Eight to twelve weeks: Same as above with full weight bearing is permitted.

During First week: Hand elevation. Range of motion exercises to the shoulder, elbow and digits are started after 3-5 days but not in cases of excision. Second week: Sutures are removed. Remove splint in open reduction and internal fixation cases but apply splint or cast in cases of excision. Active range of motion to shoulder, elbow, wrist and digits. No active movements for elbow in excision.

Four to six weeks: Active elbow extension is begun while the active elbow flexion is continued. No range of active elbow movements are still permitted for excision cases. Eight to twelve weeks: Resistive exercise to the elbow followed with gentle strengthening exercises to the elbow are begun.

 Capitellum

is the anterior portion of the lateral humeral condyle. This fracture is unique in being intra-articular always.

 Fall

on an outstretched hand, with flexion or extension of the elbow and the resulting shear forces through the radical head slices the capitellum.

 Based

on the size of the articulating fragments, it is classified into three; Type I (Hahn- Steinthal variety) This involves a large portion of the capitellum and a small chunk of trochlea with less of subchondral portion. Type II (Kocher- Lorenz variety) Here only a large portion of the capitellum is involved with the huge chunk of sub-chondral bone. Type III Comminuted fracture.

 The

patient complains of pain and swelling over the lateral aspect of the elbow. Elbow and forearm movements are also restricted.

 Conservative

treatment: In fresh fractures, closed reduction under GA and an above elbow POP casting is done for 3-4 weeks. Surgical management: Open reduction and internal fixation: This is done where closed reduction fails. Excision of the fragment: In late cases, excision of the fragment causing a flexion block is advocated.

During the cast treatment: Active exercises to the fingers, shoulders etc. is advised. After the cast removal: Thermotherapy to reduce pain and swelling. Elbow mobilization. This is described in posterior dislocation of the elbow and consists of: Using an elbow mobilizer. Active assistive or free active forearm supination or pronation is advocated. Active movements of the elbow using a wand is begun after the pain subsides.

 Fractures

of the coronoid process of the ulna were earlier thought to be an avulsion fracture involving the brachialis muscle.

 This

fracture occurs due to the impact of the coronoid process against the trochlea following a fall on an outstretched hand.

 Type

I Avulsion fracture of the tip of the coronoid. Type II Fracture involving greater than 50 percent of the coronoid. Type III Fracture involving the base of the coronoid.

 Isolated

fractures of the coronoid process are usually rare and are usually associated with greater elbow trauma. Clinical features like pain, swelling, deformity, movement restriction of the elbow, etc. depends on the extent of damage.

 Small

un-displaced fractures can be managed conservatively with an above elbow plaster cast.
fractures need open reduction and internal fixation with screw or wires.

Displaced

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OF ORTHOPEDICS BY EBNEZAR. J

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