Upper Limb Injuries Part 2

Upper Limb Fractures Part 2 Dr. Apoorv JainDOrtho, DNB Orthodrapoorvjain23@gmail.com+91-9845669975

The elbow joint is a modified hinge joint formed by 3 separate articulations,Ulnotrochlear(hinge)Radocapitellar(rotation)Proximal radioulnar(rotation)

Ligaments1- Radial collateral lig.2- Anular lig. Of radius3- Ulnar collateral lig.4- Transverse lig.

Ulnar ligament is also known as the medial collateral ligament. It prevent abduction of elbow joint. It cosists of 3 bands: Anterior, posterior, Transverse.Radial ligament is also called as the lateral collateral ligament.it prevent adduction of elbow

The soft tissue restriants can be divided intoStatic stabilizersDynamic stabilizers

Static stabilizers include:Joint capsuleLCL & MCLDynamic stabilizers include Biceps, Brachialis & Triceps

Stability is contributed by:Antero-posterior: Trochlea-olecranon fossaCoronoid fossaRadiocapitellar jointBiceps-triceps-brachialis Valgus: Medial collateral ligament complex Anterior capsuleRadiocapitellar jointVarus:Lateral collateral ligament is staticAnconeus muscle is dynamic stabilisaer

Two set of movements occur at the elbow:

A)Flexion and extension at the Ulnotrochlear jointB)Pronation and supination at Superior radio-ulnar joint

Normal range of motion:0 to 150flexion85 supination & 80 pronationFunctional range of motion:a 100 arc (30 to 130 degrees flexion)50 supination & 50 pronation

Movement of elbow

Dislocation of the elbowDislocation of UlnoHumeral joint Mechanism of injury:Most commonly injury is caused by fall onto an outstretched hand or elbowPosterior dislocation: a combination of elbow hyperextention, valgus stress, arm abduction and forearm supinationAnterior dislocation: a direct force strikes the posterior forearm with elbow in flexed position

Most elow dislocations & fracture dislocations result in injury to all capsulo-ligamentous stabilizers of elbow jointThe capsuloligamentous injury progresses from lateral to medial (HORI CIRCLE)

Signs and SymptomsPain, Swelling and EcchymosisInstability, Crepitus and Deformity(With the elbow flexed at 90 degrees,the medial & lateral epicondyles & olecranon process should from isosceles triangle) A complete peripheral neurological examination for both motor & sensory functions should be done Radial & ulnar pulses should be compared on both sides

ClassificatonAccording to direction of displacement of ulna relative to the humerus PosteriorPosterolateralPosteromedialLateral MedialAnterior

Treatment principlesRestoration of the inherent bony stability is goal

Ulnotrochlear and Radiocapitellar contact.The LCL is more important than MCL in setting of most cases of traumatic elbow instabilityMCL will usually heal properly without any repair

Parvins method Of Closed reductionPatient lies prone Physician applies gentle downward traction of the wrist for few min, as the olecranon begin to slip distally, the physician lift up gently on the arm

Meyn and Quigleys method of reduction: Only the forearm hangs from the side of the stretcher as gentle downward traction is applied on the wrist, the physican gudies the reduction of olecranon with the opposite hand

Surgical repair (if elbow clinically is unstable post reduction)

Direct repair of the ligaments,capsule and musclesStatic or Hinged external fixator applicationCross pining of the jointTemporary bridge plating of the elbow

If the elbow remains unstable inspite of repair to lateral structures the medial side of the elbow is approached with care taken to protect the ulnar nerve

If the elbow is still unstable then an External fixator should be placed

Complications

Vascular injury of brachial artery may occurNerve injury the medial ulnar nerve may be affected Myositis ossificans which is more common if passive exercise is inflicted on the patient.Late complications StiffnessHeterotopic ossificationUnreduced dislocationRecurrent dislocationOsteoarthritis after severe fracture dislocation.

RADIAL HEAD FRACTURE

EPIDEMIOLOGY 4% of all fractures and 30% of all elbow fractures1/3 patients associated injury to shoulder, humerus, forearm,wrist or hand.

Rare in children due to cartilagenous nature of radial headRadial neck fracture more common in children

Anatomy of proximal radius

RadioCapitellar joint transmit 50-60% load across elbow

Radius Head Surgical Anatomy

Important for:Valgus StabilityPosterolateral Rotatory StabilityLongitudinal Forearm Stability(Along With Interossi Membrane & Druj)

Elbow Stability

MCL & Ulnohumeral Joint: Primary StabilizerRadial Head & Capsule: Secondary Stabilizer

Mechanism Of Injury (1) Fall On Outstreched Hand (most Common) Distal Radius

Interossi Membrane(forearm)

Radial Head Impaction Against Capitellum

(2) Valgus Injury To Elbow/Direct Injury

Mcl Rupture/Olecranon Fracture Unstable Elbow

Signs and Symptoms

Swelling EcchmosisAnconeus Triangle FullnessRange Of Motion RestrictionStabilityActive Finger Extension

Forearm/Interossi Membrane TendernessWrist Tenderness

ESSEX LOPRESTI Lesion

Essex Lopresti LesionThis is defined aslongitudinal disruption of forearm interosseous ligament,usually combined with radial head fracture and/or dislocationplus distal radioulnar joint injury

Muscle Attachment Around Proximal Radius:SUPINATOR ATTACHMENT AT PROXIMAL RADIUS.BICEPS TENDON ATTACH TO RADIAL TUBEROSITY.

Posterior Interossei Nerve At Risk:Posterior Interosseous Nerve Traverses From Anterior To Posterior Through Supinator Muscle.Always Check Pre Operative Active Finger Extension

Radiographic FindingsSTANDARD AP AND LATERAL X RAY of elbowOBLIQUE(GREEN SPAN)VIEWFOREARM AND WRIST X RAY IF REQUIRED

X RAY FINDINGS

Classification Of Radial Head FracturesMason classificationType IMinimally displaced, no mechanical block to rotation,intraarticular displacement 2mm or angulated, possible mechanical block to forearm rotationType IIIComminuted and displaced fx, mechanical block to motionType IVRadial head fracture with elbow dislocation

MORREY MODIFIED MASON CLASSIFICATION BY QUANTIFYING DISPLACEMENT AREA >30% AND DISPLACEMENT OF >2 MM

TreatmentGoalCorrection Of Any Block To Forearm Rotation

Early Mobilisation Of Elbow And Forearm

Stability Of Elbow And Forearm

Prevention Of Secondary Osteoarthrosis Of Elbow

Non Operative TreatmentIndication:Isolated Radial Head Fracture With Mason Type 1 (Undisplaced 2 mmMason type III where ORIF feasible(>3 FRAGMENT POOR OUTCOME)Mechanical block to motion (lignocaine inj in elbow joint)Presence of other complex ipsilateral elbow injuries(without metaphyseal bone loss)

FRAGMENT EXCISION LEADS TO INSTABILITY

TRY TO PRESERVE SMALLEST FRAGMENT

PRONATE FOREARM WHILE FIXATION

Which implant to use?

Mini fragment screw(2.4 or 2.7 mm)(counter sink must)Headless compression compression screw/Herbert screwLow profile plate/mini t plate(in safe zone/postero lateral)K WIRE

COMPLICATION OF ORIFPIN INJURY

HARDWARE FAILURE

HARDWARE IMPINGEMENT

STIFFNESS OF ELBOW

RESTRICTION OF SUPINATIONPRONATION

Radial Head ReplacementTo prevent proximal migration of the radiusSilicon implant poor outcome : SILICON SYNOVITISTitanium/vitallium metallic implant of choice

RADIAL HEAD EXCISION

INDICATION:Low demand, sedentary patientsIn a delayed setting for continued pain of an isolated radial head fracture

CONTRAINDICATION:In childrenPresence of destabilizing injuries (Essex-lopresti lesion,fracture dislocation elbow(mason type 4),monteggia)Terrible triad of elbow(coronoid fracture,MCL deficiency)

Distal Radius FracturesCommon injury

Potential for functional impairment and frequent complications

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HISTORYFirst surgeon to recognize these injuries was Pouteau 1783. His work was not widely publicized.Later Abraham Colles 1814 gave the classic description of Colles fractureAdvent of X rays at the end of nineteenth century contributed much to the understanding of different patterns of injury.

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Incidence

One sixth of all fractures treated in the Emergency Room (16%)

Bimodal distributionless than 30 years(70% men)over 50 years(85% women)Males age 35 or older - 90 per 100,000 population

IntroductionOccurs through the distal metaphysis of the radiusMay involve articular surface.Mechanism of injuryforced extension of the carpus, impact loading of the distal radius.

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Diagnosis: History and Physical FindingsHistoryWrist is typically swolen with ecchymosis and tenderVisible deformity of the wrist, with the hand most commonly displaced in the dorsal direction less comonly in volar directionMovement of the hand and wrist are painful. Adequate and accurate assessment of the neurovascular status of the hand is performed, before any treatment is carried out.

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Diagnosis: Diagnostic Tests and ExaminationGeneral physical exam of the patient, including an evaluation of the injured joint, and a joint above and below

Radiographs of the injured wrist-pa and lat view , oblique view

CT scan of the distal radius to know extent of intrarticular involvement

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Osseous AnatomyDistal radius 80% of axial loadScaphoid fossaLunate fossaSigmoid notch DRUJ

Distal ulna

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Anatomy Scaphoid and lunate fossaRidge normally exists between th