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Injuries to the Elbow and Forearm. Tintinalli Chapter 270. Posterior Elbow Dislocation. Mechanism: FOOSH (fall on an outstretched hand) Clinically: held in 45 degree flexion, prominent posterior olecranon, significant swelling Assess neurovascular status before and after reduction

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injuries to the elbow and forearm

Injuries to the Elbow and Forearm

Tintinalli

Chapter 270

posterior elbow dislocation
Posterior Elbow Dislocation
  • Mechanism: FOOSH (fall on an outstretched hand)
  • Clinically: held in 45 degree flexion, prominent posterior olecranon, significant swelling
  • Assess neurovascular status before and after reduction
    • Ulnar, radial, median nerve fxn and brachial artery
  • X-ray: lateral-ulna & radius displaced posteriorly
  • Reduce under conscious sedation. Distal traction at wrist with humerus immobilization. Flex the elbow with posterior pressure to the distal humerus. Post reduction films.
anterior dislocations
Anterior dislocations
  • Mechanism-elbow flexed with a blow to the olecranon.
  • Forearm is elongated and supinated
  • Higher incidence of vascular damage
  • Reduction: immobilize the humerus with in-line traction to the wrist and downward/backward pressure on the proximal forearm
radial head subluxation
Radial Head Subluxation
  • Children<5 y.o.
  • MOI-longitudinal traction on the hand or forearm with arm in pronation
  • Presents: elbow flexed and arm in passive pronation, unwilling to move it
  • Xrays are usually normal
  • Reduce by placing the thumb on the radial head and supinating the forearm and flexing the elbow
elbow radiograph
Elbow Radiograph
  • Post. Fat pad-never normal on x-ray. Represents swelling of the joint capsule and probably fx.
  • Ant. Fat pad-a small one may be present on normal x ray. If superior and anteriorly displaced, could represent a fracture.
  • Anterior humeral line-line down the ant. surface of the humerus normally transects the middle of the capitellum. With a supracondylar extension fracture the line may transect the ant. 1/3 or completely ant. to the capitellum
elbow radiograph1
Elbow Radiograph

Fat Pad Sign

supracondylar extension fracture
Supracondylar Extension Fracture
  • MOI: FOOSH
  • Clinically: edema, tenderness at elbow, olecranon prominent, depression proximally over triceps
  • X-ray: Posterior fat pad, tranverse fx line
  • Treatment
    • Nondisplaced: ortho consult-post. splint with the arm at 90 degrees
    • Displaced: require surgical reduction. If vascular compromise, try to reduce once in the ED
supracondylar flexion fractures
Supracondylar Flexion fractures
  • MOI: direct anterior force against flexed elbow
  • Xray: anterior displacement of distal fragment (frequently open)
  • Treatment
    • Nondisplaced-immobilization with early ortho follow up
    • Displaced-emergent ortho consult for reduction and pinning
distal humerous fractures
Distal Humerous Fractures
  • Epicondyle Fractures
    • Lateral (rare)
        • Avulsion usually
        • Immobilize in 90degrees flexion, ortho referral one week
    • Medial
        • MOI: repeated valgus (throwing) or direct blow
        • Presentation: pain over medial elbow worse with supination
        • Risk: ulnar nerve injury
        • Tx: nondisplaced – nonoperative; displaced – internal fixation
distal humerous fractures1
Distal Humerous Fractures
  • Condylar fractures
    • Lateral (more common)
      • Children
      • MOI: direct blow, FOOSH, varus stress
    • Medial
      • Children
      • MOI: transmitted force from ulna, FOOSH, valgus
  • Treatment
    • Ortho consult for surgical correction
radial head fractures
Radial Head Fractures
  • Most common fx of elbow
  • MOI: FOOSH
  • Clinically: pain in lateral elbow with pronation & supination
  • Xray:
    • Radiocapitellar line: line drawn from center of radial shaft should transect radial head and capitellum
    • Abnormal fat pad
  • Tx
    • Displaced: surgical
    • Nondisplaced: sling immobilization, ortho referral 1 week
olecranon fractures
Olecranon fractures
  • MOI: direct blow to point of elbow, FOOSH with elbow flexion
  • Clinically: pain posterior elbow, swelling, crepitus
    • Triceps function may be compromised
    • Ulnar N. injury common
  • Tx
    • Nondisplaced: immobilize in flexion, forearm neutral
    • Displaced >2mm ORIF
forearm fractures
Forearm Fractures
  • Radius and ulna: joined by interosseous membrane results in injury to both
  • Requires high force, MVA, fall from height
  • Complications: reduced sup/pro, osteo, neurovascular compromise, compartment syndrome, Volkmann’s contracture
nightstick fracture
Nightstick Fracture
  • Isolated Ulnar Fracture
    • MOI: Direct blow to forearm (defensive)
  • Tx
    • Nondisplaced: long arm splint, close f/u
    • Displaced >10 degrees of angulation or >50% of the width: ORIF
galeazzi fracture
Galeazzi fracture
  • Fracture of distal third of radial shaft with a distal radioulnar dislocation
  • MOI: FOOSH in forced pronation, direct blow
  • Xray
    • Short oblique or tranverse with dorsal lateral angulation
    • Radioulnar joint injury subtle (increased distal radioulnar joint space on AP view)
  • Tx: ORIF
monteggia s fracture dislocation
Monteggia’s Fracture-Dislocation
  • Ulnar shaft fx with radial head dislocation
  • Four Types:
    • Type I: prox/middle 1/3 ulna, ant dislocation radial head
    • Type II: prox/middle 1/3 ulna, post dislocation
    • Type III: fx ulna distal to coronoid process, lateral dislocation
    • Type IV: prox/middle 1/3 ulna and fx prox 1/3 of radius with ant dislocation
monteggia fracture dislocation
Monteggia Fracture-Dislocation
  • Clinically
    • radial head palpable in anterolateral or posterolateral location
    • Forearm may appear shortened and angulated
  • Xray
    • Ulnar fx clearly visible, may overshadow less obvious radial head dislocation
  • Tx
    • ORIF of ulna
    • Closed reduction of radial head dislocation
biceps rupture
Biceps Rupture
  • Proximal (long head)
  • MOI: repetitive microtrauma (chronic bicipital tenosynovitis), sudden contraction vs resistance
  • Snap/pop, pain in anterior shoulder, mid arm “ball”
  • Xray: look for avulsion fx
  • Tx: sling, ice, analgesics, ortho referral
triceps rupture
Triceps Rupture
  • Rare
  • Distal more common, young men
  • MOI: FOOSH causing forceful flexion of extended forearm, direct blow to olecranon
  • Clinically: sulcus with a more proximal mass, if complete- inability to extend forearm
  • Xray: look for avulsion of olecranon
  • Tx: sling, ice, analgesics, ortho referral
    • Compete tear: surgery
    • Partial tear: immobilization