052 - Humerus and Elbow

Who gets transcondylar fractures?

- Elderly - Get ortho consult in ED

Describe management of posterior elbow dislocation

- XR and neurovascular exam before and after - Intra-articular injection of bupivacaine and procedural sedation - Reduction (see next) - Post-reduction care 1. Move elbow through gentle ROM - ensure joint stable 2. Immobilize in 90 degrees flexion with posterior splint 3. Re-check neurovascular status get x-ray

List 4 important ligamentous structures of the elbow

1. Annular ligament (Nursemaid's elbow) 2. Radiocollateral ligament 3. Ulnar collateral ligament 4. Anterior capsule

List steps in reducing a displaced supracondylar fracture

1. Firm traction inline w/ long axis 2. Correct medial or lateral displacement with hand at elbow 3. With thumb over anterior surface of proximal fragment and fingers behind the olecranon, elbow is gentle flexed to just beyond 90 degrees 4. MEDIALLY displaced #: - Immobilize in PRONATION (to tighten brachioradialis and common extensors) 5. LATERALLY displaced #: - Immoblization in SUPINATION (closes the fracture medially) 6. Apply posterior slab splint - Avoid circumferential casts as they can increase the risk of compartment syndrome 7. Child should be admitted for neurovascular monitoring of the forearm - (We sent for walking wounded usually)

List 8 indications for ORIF of a humeral shaft fracture

1. Open # 2. Multiple injuries precluding mobilization 3. Bilat # 4. Poor reduction 5. Poor patient compliance 6. Failure of closed treatment 7. Pathologic fractures 8. Radial nerve palsy after manipulation

4 indications for immediate ortho referral in ED for humeral shaft #

1. Open # 2. Severely displaced 3. Communited # 4. Radial nerve injury (occurs in 20%!!) 5. An associated forearm fracture in same extremity

The most common epicondylar # = medial Describe the various mechanisms of this fracture

1. Posterior elbow dislocation (avulsion #) 2. Repetitive valgus stress (throwing baseball) - Little Leaguer's elbow 3. Arm wrestling (avulsion #) 4. Direct blow

List 9 risk factors for biceps tendon rupture

1. Unexpected extension force to flexed arm 2. Underlying tendonitis 3. DM 4. CRF 5. SLE 6. RA 7. Steroid use 8. Fluoroquinolone use 9. Smoking

What is the management of a lateral condyle fracture?

2nd most common elbow # in kids FOOSH + varus stress on extended arm MGMT Minimally displaced (< 2mm) = cast or posterior splint held in flexion - Lateral: forearm supinated, wrist extended - Medial: forearm pronated, wrist flexed Displaced (> 2mm) - ORIF or closed reduction w/ pins

Describe the ED management of medial epicondyle #

< 5 mm displacement = posterior splint - Elbow and wrist and flexed and forearm pronated > 5 mm displacement = ORIF If a patient is high-performance athlete - probably will get ORIF even w/ minimal displacement Any intra-articular involvement = ORIF

DDx for a sail sign or posterior fat pad in adults vs. peds?

Adults - Radial head fracture (#1) - Other elbow fracture - Gout - Hemarthrosis - Septic joint - Bursitis Peds - Supracondylar fracture NOTE: if severe fracture (ie. capsule bursts), you may not see the fat pads on x-ray

Define Baumann's angle in regards to a pediatric elbow x-ray

Angle between lone axis of humerus and the growth plate of the capitellum Should be ~ 75 degrees

List the components of the anterior and posterior compartments of the arm

Anterior compartment - 3 muscles (biceps brachii, brachialis, coracobrachialis) - brachial artery - 3 nerves (ulnar nerve, median nerve, musculocutaneous nerve) Posterior compartment - Triceps brachii - Radial nerve

What lines should you always look at when examining elbow XR?

Anterior humeral line - Should bisect anterior 1/3 of capitellum Radiocapitellar line - Should bisect the middle of the capitellum

What structures are commonly injured in posterior elbow dislocation?

Brachial artery Median nerve

What are the ossification centres of the elbow? What age do they appear?

CRITOE - Capitellum 1 - Radial head 3 - Internal condyle 5 - Trochlea 7 - Olecranon 9 - External condyle 11

How do you reduce a posterior elbow dislocation?

Can also try interlocking hands method

List early and late complications of elbow dislocations

Early - Associated / multiple # - Brachial artery injury - Median nerve injury (can also cause ulnar > radial) - Joint capsule disruption - ST injury & swelling Late - Late brachial artery compromise - Post reduction median nerve entrapment - Post traumatic stiffness - Post traumatic joint instability - Ectopic ossification (myositis ossificans) - Occult DRUJ disruption

Where do wrist flexors and extensors originate?

Flexors = medial epicondyle Extensors = lateral epicondyle

Describe the classification system for pediatric supracondylar fractures

Gartland classification I - fracture without displacement II - displaced fracture of anterior cortex with posterior cortex intact III - displaced fracture with anterior and posterior cortices fractured IIIA - no rotation IIIB - rotation present

Describe the pronation method for reduction of Nursemaid's elbow

Hyperpronation + FLEXION at 90 degrees Higher success rates on first attempt

Describe the influence of muscles on the displacement of a humeral shaft facture

If the fracture is proximal to the attachment of the pectoralis major muscle: - Distal segment of humerus is pulled superiorly and medially by the pectoralis muscles If the fracture is between insertion of pec major and deltoid uscles - Humeral neck is pulled superiorly and medially by pectoralis muscles - Distal part of humerus is pulled laterally and superiorly by deltoid muscles If the fracture is distal to deltoid insertion - Proximal part of the fracture is pulled laterally and superiorly by the deltoid muscles - Distal part is pulled superiorly and medially by the biceps and triceps muscles

How will a child typically present with a "Nursemaid's Elbow" How do you treat this?

Kid will hold elbow slightly flexed and forearm will be pronated MOA = sudden pull on the extended, pronated arm Reduction: - Supination and flexion - Hyperpronation (higher success rate)

What is the main landmark used when assessing a condylar fracture for stability?

Lateral trochlear ridge - If involved = unstable # (for both lateral and medial condyle fractures)

What is the management of olecranon fractures?

Mechanism: - Direct blow, fall, assault, MVC MGMT: Undisplaced - posterior splint in flexion, analgesia - Close ortho FU - ROM exercises in 3 weeks Displaced (> 2 mm) - Ortho to see in ED - ORIF

What is the management of a capitellar fracture?

Mechanism: - FOOSH - radial head necks the capitellum off - Always suspect an associated radial head fracture MGMT - Ortho in ED - These # need to get reduced and pinned (usually ORIF) - Need accurate anatomic alignment for good functional outcome Potential complications - Arthritis, restricted ROM, AVN of fracture fragment

What is the management of radial head fractures?

Mechanism: - FOOSH, radial head hits the capitellum Common associated injuries - Damage to articular surface of capitellum - Injury to collateral ligament Management depends on classification of fracture

Management of anterior elbow dislocation?

Mechanism: - Direct posterior blow onto the olecranon with elbow flexed - Huge amount of force invlved - Often have neurovascular compromise - Can have avulsion of triceps mechanism MGMT - Same as posterior for most things, see next for reduction

What is the structure most at risk of injury with a supracondylar fracture or posterior elbow dislocation? What is the function of this structure?

Median nerve - Thumb flexion, opposition - Flexion of D2-D3 - Wrist flexion, radial deviation (abduction) - Forearm pronation Neuropathy can result in carpal tunnel syndrome and monkey hand

List the bursae of the elbow. Which one is most prone to infection?

Olecranon bursa - between olecranon and posterior skin - MCC of infection Radio-humeral bursa Biceps tendon bursa

What nerve is commonly injured in a supracondylar #?

Posterior interosseous nerve = #1 - Branch of radial nerve - PIN is also injured in Monteggia fractures (Proximal Ulna, Radial head D/L, PIN) Others (in order) - Radial nerve - Median nerve (especially in posterior dislocation) - Ulnar nerve

Describe the mechanism and management of a nursemaid's elbow

Radial head subluxation Mechanism - Longitudinal traction on the arm with wrist in pronation - Annular ligament stretches / tears and fibers capitellum and radial head - kid can't supinate arm - Arm is held in slightly flexed and pronated position MGMT - Reduction: supination vs pronation methods

What structure is most at risk of injury with a midshaft humerus fracture? What is the function of this structure?

Radial nerve - Innervates extensors of the arm, wrist and fingers - Allows for supination of forearm - Neuropathy can cause wrist drop

What are the muscles of the rotation cuff?

SITS - Supraspinatus - Infraspinatus - Teres minor - Subscapularis

How do you treat a non-displaced or minimally displaced humerus shaft fracture in the ED?

Sugar tong splint and a sling

What are the indications for XR in the case of radial head subluxation?

Swelling or deformity Atypical story Child does not resume use after reduction (give ~ 30 min) Suspicion of child abuse Tenderness of forearm, wrist or humerus

Describe the articulations of the elbow

Trochlea (medial condyle) articulates with the olecranon (infero-posterior) and coronoid process (anterior) of ulnar Capitellum (lateral condyle) articulates with the radial head

What is the management of supracondylar #

Type I - Splint / cast with elbow in 90 degrees x 3 weeks - Stable fracture, OP ortho Type II - Might get ortho in ED (depending on f/u and ED doc level of comfort) - Reduce and splint in 90 degrees flexion at elbow - Close ortho FU - may need to get pinned Type III - UNSTABLE. Ortho in ED. - These will get surgical intervention - ORIF vs. closed fixation + pinning

How do you classify radial head fractures?

Type I - Undisplaced - Sling x 24-48 hours then early ROM (physio) - Consider hematoma block Type II - Marginal # ( 30% articular surface, > 2mm displacement - Immobilization (splint) and early ROM - dictated by ortho Type III - Comminuted radial head # - Call ortho - sometimes need to perform radial head excision Type IV - Any type of I-III with associated elbow dislocation - Reduce elbow dislocation and treat associated fracture - Ortho in ED

How are FLEXION type supracondylar fractures classified? (<2 % supracondylar #)

Type I - Undisplaced or minimally displaced Type II - Displaced with anterior cortex intact Type III - Completely displaced - Distal fragment migrates proximal and anterior

What structure is most at risk of injury with a medial condylar or olecranon fracture? What is the function of this structure?

Ulnar nerve - Finger adduction and abduction - Flexion of D4 and D5 - Wrist flexion - Wrist adduction Neuropathy can cause a claw hand (hand of Benediction)