Elbow, forearm injuries. K. Fekete

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1 Elbow, forearm injuries K. Fekete 1.

2 Outline: Fractures of the elbow Dislocation of the elbow Fractures of the forearm Special injuries 2.

3 ANATOMY 3. Lennard Funk

4 Anatomical reminder Three joints: Humero-ulnar j. Humero-radial j. Prox. radio-ulnar j. 4.

5 The elbow has a tendency towards contracture! Contracture: Temporary or permanent stiffness or narrowing of function of the joint. 5.

6 BIOMECHANIC I Valgus position Baumann angle

7 The position of the trochlea: The trochlea and the pivot point of the elbow is not located in the continuation of the humerus, it is actually placed ventrally to this aaa.avi /hyperextension /150

8 Humeral-trochlear angle

9 BIOMECHANIC II. The role of the humeral-trochlear angle

10 10. In this position that the elbow is in its most stable position as well

11 BIOMECHANIC III. The distal end of the humerus similar to the front fork of a bicycle! 11. basic condition: restoration of the radial and ulnar columns and the axis

12 Examination Signs of fracture: swelling pain deformity crepitation abnormal mobility Signs of joint dislocations: swelling pain deformity flexible immobilization 12.

13 Assessement of nerve and vascular damages: N.radialis N.medianus. N.ulnaris 13.

14 THE WELL-KNOWN DANGERS: Vessel injury (Volkmann ischemic contracture) 14.

15 Volkmann ischemic contracture 15. Art. brachialis

16 DIAGNOSTIC bi-directional x-ray CT, 3D-CT 16.

17 17. DSA

18 Fractures of the distal humerus: CLASSIFICATION (AO, ASIF) 18.

19 EXTRAARTICULAR FRACTURES radial epicondyle injury ulnar epicondyle injury (A1) supracondylar fractures (A2) 19.

20 Ulnar epicondyle injury ORIF: Open reduction, Internal fixation. Treatment: open reduction, and fixation with pins or tension band wires. 20.

21 ULNAR EPICONDYLE INJURY MISTAKE: ABSENCE OF APPROPRIATE 21. DIAGNOSIS

22 22. RADIAL EPICONDYLE INJURY

23 SUPRACONDYLAR FRACTURES Mainly in children! 4 weeks 0 8 weeks 0 4 weeks 8 weeks 13 Y. boy. 23.

24 THE DIFFERENCES IN THERAPY: In children: closed reduction pinning casting In adults: stable internal fixation without plaster casting 24.

25 THE DIFFERENCES IN THERAPY: Supracondylar fractures in adults are usually treated operatively with plate and screws 59 Y Mo Mo.. 25.

26 Supracondylar fr. (39 Y.) 6 Weeks 26. Casting should be avoided!

27 Intra-articular fractures FRACTURES OF THE RADIAL AND ULNAR CONDYLE FR. OF THE HUMERAL HEAD TROCHLEAR FRACTURES INTERCONDYLAR FRACTURES 27.

28 Fractures of the intra-articular surface of the joint are serious injuries The elbow will certainly be stiff without operative treatment! 30 % contracture! (in certain publications!) 28.

29 FRACTURES OF THE ULNAR CONDYLE Neglected treatment. Pseudoarticulation. 29.

30 FRACTURES OF THE ULNAR CONDYLE B2 fracture 37y Total stiff elbow 30.

31 OLECRANON CAPITULUM HUMERI 31. OLECRANON TROCHLEA

32 3 MO P.OP. 32.

33 TROCHLEAR FRACTURES 33.

34 TROCHLEAR FRACTURE Fr. Type B3, 18y 6 MO. 6 MO. 6 MO MO.

35 Osteotomy of the articular surface 35.

36 6 MO. L R weeks p. op. 4 years later

37 37. FR. OF THE HUMERAL HEAD (CAPITULUM HUMERI)

38 38. FRACTURE OF THE CAPITULUM HUMERI The fracture piece can be removed!

39 FR. OF THE HUMERAL HEAD Neglected therapy! Conservative treatment of a dislocated fracture 39.

40 2. Mo. 10. Mo. 40.

41 41. 4 years later...

42 Y. FRACTURE (pseudoarticulation)of THE CAPITULUM HUMERI

43 INTERCONDYLAR FRACTURE The main idea: exact reconstruction of the joint! 43.

44 POSITION AND APPROACHES Laying on the sound side Prone position The arm propped up 44.

45 HABITUAL INCISION is on the dorsal side 45. ANCONEAL FLAP

46 46. osteotomy of olecranon: better visualise the joint surface

47 47. INTERCONDYLAR FRACTURES 1. Anatomical reposition of the articular surface

48 48. INTERCONDYLAR FRACTURES 2. stationary immobilization with screws and provisional fixation

49 49. INTERCONDYLAR FRACTURES 3. Restoration of the two lateral column

50 IMPLANTS Current standard New standard 50. SYNTHES

51 Distal Humerus Plates (DHP). Functional therapy may be commenced immediately following surgery! 51. SYNTHES

52 52. Fracture of the proximal ulna:

53 Distractional fracture of the olecranon Treatment: Tension-band wiring 53.

54 26 y months 54.

55 55. Olecranon fracture. Plate and screws

56 Fr. of the prox. ulna 6 Month after injury 56.

57 FRACTURE OF THE PROXIMAL RADIUS conservative and functional therapy: plaster casting 3-4 days, careful exercises Operative treatment 57. Fracture classification is associated with Mason 50.

58 Radial head fr. Mason I. Functional treatment 6 weeks after injury 58.

59 Fracture of the proximal radial head (Mason 2.) In cases of large dislocation, operative incision and screwing is performed 59.

60 Mason 2. Mini plate fixation 60.

61 MASON 3. fr. The removal of the radial head 61. Result: good mobility, but the joint is unstable!

62 MASON 3.fr. Prosthesis of the radial head Prevention of the joint instability 62.

63 63. The head is fractured into several pieces, and is not reconstructable.

64 64. The various stems and heads can be combined in various ways. This is why it is a modular prosthesis! (Designe from Debrecen)

65 65. ROM 3 Months after injury

66 ELBOW DISLOCATION: 2. Place ( 20%) after dislocation of the shoulder! RADIAL ULNAR DORSAL VENTRAL DIVERGENS COMBINATIONS 66. Dorso-radial dislocation (luxatio)

67 Dislocation (luxation): temporary or permanent separation of the joint surfaces from each other 67.

68 Dislocation of the elbow. Isolated dislocation : a dislocation without fracture 0. 3 weeks

69 Fracture dislocation in addition to the dislocation the bone or bones making up the joint are also broken 25 y. Dislocation (luxation) of the elbow, fr. of the radial neck and head 2 mo mo. 69.

70 Examination of the Hüter the two epicondyles and the tip of the olecranon form an equilateral triangle. triangle: 70.

71 71. Elbow dislocation

72 TREATMENT Reduction: under local, or general anaesthesia centesis 72.

73 Examination of stability The elbow is stable: following reduction - physical therapy can be begun after 3 days of plaster casting. Unstable: prone to re-dislocation - the elbow should be put in a right angle plaster cast for 3 weeks. 73.

74 LARGE INSTABILITY: Ulnar collateral ligament must be repaired 74.

75 75. Amsterdam. The anatomy lesson of Dr. Nicolaes Tulp Rembrandt (1632)

76 The radius and ulna are joined by the interosseous membrane 76. Assesment of the vascular and nerve function is obligatory!

77 Diagnosis: x-rays in two views are necessary 28 y. 8 weeks 77. On one x-ray the wrist should be visible and on the other the elbow joint!

78 Forearm fracture: both bones are broken 78.

79 Stable fracture: if it is transverse or jagged Casting for 6-12 weeks 79. (4-6 weeks)

80 14 y old boy. Undisplaced fr. of the ulna, dislocation of the radius. Treatment: intramedullary splinting + plaster cast for 4 weeks. 80.

81 81. 15y. 3 mo. after injury

82 Poor treatment option! months

83 Unstable fractures (diagonal, long diagonal or spiral): operation is performed - Intramedullary pinning - Plate and screws 83.

84 In open fractures: external fixation 84.

85 Absolute indications for operation: Stage II. and III. open fractures vascular injuries nerve injuries non-reducible fractures 85.

86 Isolated fracture of the ulna Parier fr.: the patient wards off a blow to the face 86.

87 Isolated fracture of the ulna weeks

88 32 y Months

89 Special injuries Monteggia injury: fracture of the ulnar diaphysis dislocation of the head of the radius Classification: BADO 89.

90 Extension typ. Monteggia inj. 47. Y Mo.

91 Treatment: Reduction of the ulna. The head of the radius is usually spontaneously reduced due to the pull of the interosseous membrane 91. Flexion typ.

92 Flexion typ. Monteggia inj. 59 y w. 5 mo. 92.

93 Special injuries: Galeazzi injury Fracture of the radial diaphysis dislocation of the distal radio-ulnar joint 93.

94 24 Y. Galeazzi injury months

95 Galeazzi injury Treatment: Stabile plate fixation months

96 96. Essex-Lopresti injury: dislocation of the radius at both joints, thus at the elbow and wrist joints, with the complete tearing of the interosseous membrane.

97

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