Chapter 52 - Humerus & Elbow

What are transcondylar fracture

- old people w osteopenia - get ortho consulted in ED

List 4 ED indications for immediate ortho referral in ED in the case of a humeral shaft fracture

- open - severely displaced - comminuted fracture - radial nerve injury (occurs in 20% of humeral #) - An associated forearm fracture in same extremity

List 8 indications for ORIF of a humeral shaft fracture

- open fracture - multiple injuries precluding mobilization - bilateral fractures - poor reduction - poor patient compliance - failure of closed treatment - pathologic fractures - radial nerve palsy developing after manipulation

the most common epidcondylar # - medial. Decribe the various mechanism of this fracture

- posterior elbow dislocation *avulsion # - repetitive valgus stress (throwing baseball) *avulsion # - little leaguer's elbow - arm wrestling *avulsion # - direct blow

What are the indications for xray in the case of radial head subluxation

- swelling or deformity - atypical story - child does not resume use after reduction (give it 30 mins) - suspicion of child abuse - tenderness of forearm, wrist or humerus

List 9 risk factors for biceps tendon rupture

- unexpected extension force to flexed arm - underlying tendonitis - DM - CRF - fluroquinolones - steroids - SLE - RA - smoking

Describe your management of a posterior elbow dislocation

- xray and neurovas exam before and after - intra-articular injection of bupivicaine and procedural sedation - see next slide for reduction technique Post reduction care - move elbow through gentle ROM - ensure joint stable - immobilize in 90 deg flexion with posterior splint - re-check neurovasc status and get xray Approaches: 1.initial recommended approach - prone 2. traction-countertraction 3. chair/back of bed method

List the steps in reducing a displaced supracondylar fracture

1. Firm traction inline with long axis 2. Correct medial or lateral displacement with hand at elbow 3. with thumb over anterior surface of the proximal fragment and fingers behind the olecranon, the elbow is gently flexed to just beyond 90 degrees Medially displaced fractures: - immobilized in pronation (to tighten brachioradialis and common extensors) Laterally displaced fractures: - immobilized in supination (closes the fracture medially) apply post slab splint - avoid circumferential casts as they increase risk of comp syndrome Child should be admitted for neurovasc monitoring of frearm US text ... we send walking wounded usually

What do you do with a lateral condyle fracture

2nd most common elbow # in kids FOOSH + varus stress on the extended arm Management - minimally displaced (<2 mm) = cast or posterior splint held in flexion lateral: forearm supinated wrist extended medial: forearm pronated, wrist flexed displaced (> 2 mm) - ORIF or closed reduction w pins

Describe the ED management for a medial epicondyle fracture

<5 mm displacement = posterior splint - elbow and wrist are flexed and forearm pronated >5 mm displacement = ORIF if the patient is a high-performance athlete - probably will go get ORIF w minmal displacement any intra-articular involvement = ORIF

List 4 important ligamentous structures of the elbow

Annular ligament radial collateral ligament ulnar collateral ligament anterior capsule

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

Anterior Compartment 3 muscles - biceps brachii m - brachialis m - coracobrachialis m - brachial artery 3 nerves - ulnar nerve - median nerve - musculocutaneous nerve Posterior compartment - triceps brachii m. -radial nerve

What lines should you always look at when examining an elbow xray?

Anterior humerus line radiocapitellar line

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

Bursae: olecranon radio-humeral bursa biceps tendon bursa olecrenon bursa - between olecranon and posterior skin - most common site of infection

List early and late complications of elbow dislocations

Early: -associated multiple #s - brachial artery injury - nerve injury: median (can also cause ulnar> radial) - joint capsule disruption - soft tissue injury- swelling Late: - late brachial artery compromise -post eduction median nerve entrapment -post traumatic joint instability - ectopic ossification (myosistic ossificants) - occult distal raio-ulnar joint disruption

98% of peds supracondylar fractures are of the extension type. Explain the mechanism of this injury.

Fall on outstretched arm produces hyperextension of elbow

Describe the classification for pediatric supracondylar fractures

Gartland Type 1 - minimally displaced Type 2- displacement of the fracture but with the posterior cortex intact Type 3- displaced, no cortical contact Type 3 a - no rotation of the fracture Type 3 b - rotation present

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

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

What is a capitellar fracture

Mechanism - FOOSH- radial head knocks the capitellum off - always suspect an assoc. radial head fracture Management - ortho in ED - these fractures need to reduced and pinned (usually ORIF) - need accurate anatomic alignement for good functional outcome Potential complications: Arthritis, restricted ROM, AVN of fracture fragment

Anterir elbow dislocation

Mechanism: - direct posterior blow onto the olecranon with elbow flexed - huge amount of force involved - often open and have neurovasc compromise - can have an avulsion of the triceps mechanism Management: same as posterior for most things

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

Median nerve - thumb flexion and opposition, flexion of D2-D3, wrist flexion and abduction - forearm pronation - neuropathy results in carpal tunnel syndrome

What does a normal elbow xray look like?

Normal elbow Small anterior fat pad = normal posterior fat pad = never normal fracture = sail sign anteriorly + post fat pad

What is an olecrenon fracture?

Olecanon fracture Mechanism -direct blow - fall, MVC, assault Management - undisplaced -> posterior splint in flexion, analgesia, close follow-up with ortho. ROM excersises in 3 weeks -displaced > 2mm -> ortho has to see in ED. unstable. ORIF

What nerve is the most commonly injured in a supracondylar fracture

Posterior Interosseous Nerve = #1 - branch off of radial nerve PIN is also injured in Monteggia # Others (in order): 2. radial nerve 3. median nerve (esp in posterior dislocation) 4. ulnar nerve (most common if medial condyle)

What structure is most at risk with a mid-shaft humerus fracutre

RAdial Nerve -innervates extensors of the arm, wrist and fingers - supination of forearm *neuropathy can cause wrist drop

How will a child typically present with a "Nusemaid's elbow"? How do you treat this?

Radial Head Subluxation MAO = sudden pull on the extended pronated arm Kid will hold elbow slightly flexed and forearm will be pronated reduction (2 techniques) - supination +flexion - hyperpronation

Describe the meghanism and management of a nursemaid's elbow

Radial Head Subluxation Mechanism: - longitudinal traction on the arm wrist in pronation - annular ligament stretches/tears and fibers capitellum and radial head - kid can't supinate arm - arm is held slightly flexed and pronated Management: - reduction = supination vs pronation methods not: hyperpronation + flexion has a higher sucess rate on first attempt

Describe the articulations of the elbow

Trochlea (medial condyle) -> olecranon (infero-posterior) and coronoid (anterior) of ulna Capitellum (lateral) -> radial head

What is the management of supracondylar fracture based on severity

Type 1 - splint/cast with elbow in 90 deg x 3 week - stable fracture. OP ortho Type 2 - might get ortho in ED (depending on FU and Ed doc level of comfort) - reduce and splint in 90 deg - close ortho FU. many need to be pinned Type 3 - UNSTABLE. ortho in ED. - These will get surgical intervention - ORIF vs closed fixation + pinning

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

Type 1 - undisplaced or minimally displaced Type 2 - incomplete, anterior cortex intact Type 3 - completely displaced, distal fracture migrates proximal and anterior

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

Ulnar nerve - you get claw hand - it does finger adduction and abduction -flexion of D4 and D5 - wrist flexion and adduction

What is your 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 **if severe fracture (ie the capsule bursts), you may not see fat pads on the xray.

What is Baumann's angle in regards to a pediatric elbow xray

angle of intersection b/w midshaft humerus and growth plate of capitellum should be 75 deg

what neurovascular structures are most at risk with posterior elbow dislocation?

brachial artery median nerve

Radial head fracture

radial head fracture Mechanism - FOOSH - radial head hits the capitellum Common associated injuries - damange to articular surface of capitellum - injury to collateral ligament Management depends on classification of # Type 1 undisplaced slight 24-48 hours then early ROM (physio) consider hematoma block Type 2 Marginal # (<30% articular surface), > 2mm displacement immobilization (splint) and early ROM - dictated by ortho Type 3 Comminuted radial head # Call ortho - sometimes needs to perform radial head excision Type 4 any of type 1-3 with associated elbow dislocation reduce elbow dislocation and treat the asosciated fracture ortho in ED

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

sugar tong splint for humeral shaft fracture

Where do wrist flexors and extensors originate?

wrist flexors = medial epicondyle wrist extensors = lateral epicondyle