Elbow Complex Bony Injury & Dislocation

elbow dislocation has no

specific classification system:

Timing

articulations involved

direction

degree of placement

presence/absence of fx

Simple Elbow Dislocations involve surgical interventions such as Closed Reduction due to

Possible neural injury

Ligamentous injury likely

Non-op tx for Simple Elbow Dislocations

Period of immobilization in hinged brace

3-4 weeks

Complex Elbow Dislocations/Instability involves

fracture + extensive tissue damage

Radial Head/neck most common

The Terrible Triad involves

Elbow dislocation (ulna moves posteriorly)

Radial head fracture

Coronoid Fracture

MOI for elbow terrible triad

FOOSH

Male > Female

Concurrent Dislocation

an elbow fracture results in a

Fat pad Sign

Inability to fully extend elbow ***

History of trauma

Elbow Extension Test to rule out

fracture; inability to straighten elbow after trauma

Olecranon fx are most common in elderly, displaced fx is most common type, complications include

Disruptions of triceps function

Displaced intra-articular joint fracture

surgical intervention for Olecranon Fracture

ORIF

Bone excision w/ triceps repair

complications post olecranon fracture

Loss of ROM (Extension)

Ulnar Neuropathy

Post-traumatic arthritis

Instability

Non-union, Complications w/ fixation device

Radial Head Fracture accounts for 1/3 of all elbow fractures. it occurs more often in

females than males (20-60 y/o)

Occur in 10% of all elbow dislocations

Radial Head Fracture MOI

Foosh

Direct Blow to Elbow

Hyperflexion Injury (crash into humerus)

Indications for radial head excision includes substantial fracture of radial head but UCL Intact, why?

radial side gets compressed against capitulum, so need UCL on medial side to resist against valgus stress

Indications for Radial Head Replacement

Severe fractures w/ UCL or RCL injury leading to instability

benefits of radial head replacement include a normalization of jt articulation, which restores

intrinsic stability & physiologic loading of distal ulna

↓ risk of radial head migration proximally (if not, under load radius would migrate toward ulna)

Supracondylar Fracture is common in children under the age of 10, Boys>girls; MOI

Fall on extended Elbow (growth plate)

Most common types of Supracondylar Fractures

Extension >95% vs Flexion

Olecranon acts as fulcrum

complications w/ Supracondylar Ridge Fracture include Non/Malunion → Cubitus Varus; additionally

Brachial Artery injury: Volkmann's Contracture (hand no longer functions), Compartment Syndrome

Neural Injury: Medial, Ulnar, or Radial Nerve Injuries

Complex Elbow Dislocation rehab w/ surgical fixation is immobilization for 4 weeks. Forearm position based on ligamentous instability:

Supinated to protect MCL, Pronated to protect LCL

(PT’s must try to avoid elbow stiffness)

Most Complex Elbow Dislocations will have some degree of limitation in ROM. Successful outcome after low-energy fracture shows

15-140° of ROM

More complex & articular involvement will have greater ROM limitations

Complex Elbow Dislocation rehab involves establishing controlled motion protocols early w/in

1st few days using gravity to assist

Strengthening exercises around 8-12 wks post-op

Complications of Elbow Fracture

Elbow Stiffness

Heterotopic Ossificans

Instability

Non-Union

Post traumatic arthrosis

intrinsic elbow stiffness is

tightness of capsule

extrinsic Elbow Stiffness is

tightness of muscles (elbow flexors, brachialis)

Elbow Stiffness is the most common complication of Surgical Intervention &/or Fracture. Factors impacting elbow stiffness are

thickening of anterior & posterior capsule which can lead to loss of Elbow extension & supination

elbow Stiffness Management is Prevention & Early Recognition in order to perform

early AROM/PROM

Elbow stiffness mgmt involves MT, modalities/meds for pain (HEAT) but mostly

Sustained stretching programs: Low low prolonged stretches (TERT)

high pain use AAROM

Surgical mgmt for Elbow stiffness is necessary when a contracture is present for

12 months

Lack functional ROM

Elbow OA is not generally characterized by loss of joint space (NWB) but will have appearance of

osteophytes & joint contracture usually related to past injury or trauma

Pain primary complaint: dull/achy/stiff

TEA dependent on functional expectation & other pathology (instability)

Elbow rheumatoid Arthritis involved in 50% of cases, common populations are

Females 35-45

Loss of extension ROM, jt instability

Conservative: Pain control & functional training/strengthening

Surgical: TEA

indications for Total Elbow Arthroplasty

Advanced age

Low physical demand

Chronic instability

Advanced RA, Posttraumatic OA

Ankylosis of elbow

Elbow stiffness, Functional ROM Loss

Pain

Total Elbow Arthroplasty (TEA) Constrained vs Semiconstrained outcomes

20 year survivorship: 61%

Complication rates: 20-40% (hardware loosening, infection)

Functional ranges 30-115° (Lower Functional demands)

Total Elbow Arthroplasty (TEA) rehab ensures what early?

ROM

Strengthening may be delayed depending on muscular resection for visualization

Heterotopic Ossificans (bone growth in muscle) is Ectopic bone formation in para-articular soft tissues, it has unknown etiology but high risk how long after trauma?

2 months after trauma (56% of elbow fracture/dislocation)

common location for Heterotopic Ossificans

Between brachialis & anterior capsule

Between triceps & posterior capsule

Heterotopic Ossificans is associated w/

aggressive passive mobilization of jt

Heterotopic Ossificans presentation includes pain w/ progressive

loss of ROM

Hyperemia→Swelling/Warmth

Osteochondritis Dissecans is a Lateral Compression injury in adolescents of articular surface of the capitulum due to

Repetitive activities, WBing or OH activities (adolescent baseball)

Osteochondritis Dissecans Presentation

Vague lateral elbow pain, ext ROM loss

Swelling, dull, tender to palpation at radiohumeral jt

Radiographs→radiolucency of capitulum

Panner’s Disease is loss of blood supply to growth plate of capitulum, leads to

flat capitulum

Panner’s Disease occurs in

Children 7-10 y/o

Non-traumatic: repetitive stress

Panner’s Disease signs & sxs

Dull lateral ache, joint swelling, 5-20° of ext lost

Panner’s Disease treatment

Rest, avoidance of valgus stresses

May take years to resolve

Self-limiting